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DISEASES 


OF   THE 


Stomach  and  Intestines 


BY 

ROBERT    COLEMAN    KEMP,    M.D. 

Professor  of    Gastrointestinal  Diseases  in  the  New  York  School  of  Clinical  Medicine; 
Visiting  Gastro-enterologist  to  the  New  York  Red  Cross  Hospital  ;  Gastrologist 
to  the  West  Side  German  Dispensary  ;    Consulting  Physician,  Gastro- 
intestinal  Diseases,   to  the  Manhattan    State    Hospital ; 
Meinber  American  Medical  Association 


WITH    280    ILLUSTRATIONS,   SOME    IN    COLORS 


PHILADELPHIA    AND    LONDON 

W.    B.    SAUNDERS    COMPANY 

I  9  I  o 


Copyright,  1910,  by  W.  B.  Saunders  Company 


PRINTED     IN     AMERICA 

PRESS      OF 

W.     B.     SAUNDERS      COMPANV 

PHI  LADEl-PMIA 


TO 

Wxiimm  %  ®I|omaott,  M,  i.,  fCIC.  i., 

CONSULTING  PHYSICIAN  TO  THE  ROOSEVELT  AND  RED 

CROSS  HOSPITALS  AND  LATE  PRESIDENT 

OF  THE   NEW  YORK  ACADEMY 

OF    MEDICINE, 
THIS    VOLUME    IS    INSCRIBED 
AS   A  TRIBUTE   TO    HIS    HIGH    PROFESSIONAL   ATTAIN- 
MENTS   AND    IN    REMEMBRANCE    OF    HIS 
MANY     ACTS    OF     KINDNESS, 
BY  THE  AUTHOR 


PREFACE 


In  view  of  the  excellent  works  on  diseases  of  the  stomach  and 
intestines  that  have  been  placed  before  the  medical  profession,  the 
publication  of  a  new  book  on  these  subjects  might  almost  seem  to 
be  superfluous.  From  a  great  accumulation  of  material,  it  is  often 
difficult  for  the  general  practitioner  to  select  simple  and  practical 
methods,  and  it  is  the  endeavor  that  this  volume  should  render 
service  in  this  special  direction. 

Many  physicians  have  neither  time  nor  opportunity  to  devote 
to  a  practical  clinical  course,  and  next  in  value  to  this  for  the  pur- 
pose of  instruction  is  the  employment  of  photography  to  demon- 
strate the  methods  of  diagnosis  and  treatment.  Of  this  I  have 
endeavored  to  take  advantage.  Many  of  the  illustrations  are  from 
photographs  of  patients  at  the  Manhattan  State  Hospital,  taken  by 
Mr.  Hill,  the  official  photographer,  for  whose  services  I  am  indebted 
to  the  courtesy  of  Dr.  Wm.  Mabon,  the  Medical  Superintendent. 
Some  of  the  illustrations  have  been  made  by  my  artist  from 
models. 

As  visceral  displacements  have  recently  assumed  an  important 
position,  their  symptoms,  diagnosis,  and  treatment,  notably  by  me- 
chanical methods,  are  specially  described.  Typhoid  fever  is  included 
in  this  volume  on  account  of  its  intestinal  complications  and  for  the 
purpose  of  differential  diagnosis. 

A  chapter  is  devoted  to  Diverticulitis ,  which  has  become  an 
important  subject. 

The  endeavor  has  been  made  to  indicate  as  clearly  as  possible 
the  conditions  which  call  for  surgical  procedure. 


ROBERT   COLEMAN   KEMP. 


New  York  City, 

February,    1910. 


CONTENTS 


Part  I 

CHAPTER    I 

PAGE 

Anatomy  op  the  Stomach  and  Intestines 17 

Anatomy  of  the   Stomach 17 

Anatomy  of  the  Intestines 22 

Histology  of  the  Large  Intestine 33 

CHAPTER    II 

Physiology  op  Digestion 34 

The  Gastric  Juice 35 

Intestinal   Digestion , 36 

CHAPTER    HI 

Interrogation  of  the  Patient  (History) 42 

CHAPTER    IV 

General  Methods  of  Physical  Examination ■ 45 

General   Inspection 45 

Topographic  Anatomy 55 

Physical   Examination  of  the  Liver  and  Gall-bladder 57 


Part  II 

DISEASES   OF   THE   STOMACH 

CHAPTER   V 

Methods  of  Physical  Examination  of  the  vStomach 71 

Rontgen  Rays  (x-Rays) •'^7 

Radium  Transillumination  of  the  vStomach SS 

Radium  Photographs  of  the  vStomach NS 

Conclusions -SI^ 

9 


lO  CONTENTS 

'         CHAPTER  VI 

Examination  of  the  Functions  of  the  Stomach 90 

Test  Meals 91 

Method  of  Aspiration  of  the  Gastric  Contents 91 

Examination  of  the  Ingesta 95 

Abnormal  Constituents  of  the  Stomach  Contents 113 

Microscopic  Examination  of  the  Gastric  Contents 116 

Determination  of  the  Absorptive  Function  of  the  Stomach 121 

CHAPTER   Vn 

Diet 124 

Diet  in  Health  . 1 24 

Diet  in  Disease 138 

CHAPTER    VIII 

EocAL  Treatment  of  the  Stomach 140 

Lavage 140 

Stomach  Powder-blower 159 

Electricity 161 

CHAPTER    IX 

Massage,    Vibratory    Massage,    Hydrotherapy,    Counterirritation, 

Orthopedic  Appliances 165 

Massage 165 

Vibratory  Massage 165 

Local  Hydrotherapy 168 

Counterirritation 1 70 

Orthopedic  Methods 170 

CHAPTER  X 

Catarrh  op  the  Stomach 180 

Acute  and  Chronic  Gastritis 180 

Acute  Gastritis 1 80 

Simple  Acute  Gastritis 180 

Toxic  Gastritis 185 

Phlegmonous  Gastritis 188 

Chronic  Gastritis 189 

CHAPTER    XI 

Achylia  Gastrica 203 

CHAPTER   XII 

Hematemesis,   UIvCER  of  the  Stomach,  Exulceratio  Simplex,  Acute 

AND  Chronic  Erosions 211 

Gastric  Hemorrhage -. 211 

Ulcer  of  the  Stomach 212 

Exulceratio   Simplex    (Dieulafoy)    or   Superficial   Ulceration   of   the 

Stomach 235 

Gastric  Erosions 236 

Acute  Erosions  (Hemorrhagic  Erosions) 236 

Chronic  Erosions •. 237 


CONTENTS  I I 

CHAPTER   XIII 

PAGE 

Cancer  of  the  Stomach  (Carcinoma  Ventricuu),  Other  Tumors  of 
THE  Stomach,   Apparent  Tumors  of  the  Stomach,   Foreign 

Bodies  in  the  Stomach 240 

Cancer  of  the  Stomach  (Carcinoma  VentricuH) 240 

Other  Tumors  of  the  Stomach 275 

Apparent  Tumors  of  the  Stomach 277 

Foreign  Bodies  in  the  Stomach 277 

CHAPTER   XIV 

FuNCTiONAi,  Diseases  of  the  Stomach 279 

Hyperacidity   (Hyperchlorhydria) 279 

Gastrosuccorrhea   (Continuous  Secretion  of  Gastric  Juice) 291 

Gastrosuccorrhea   (Continua  Periodica) 292 

Gastrosuccorrhea  (Continua  Chronica) 296 

CHAPTER    XV 

Disturbances  of  the  Motor  Function  of  the  Stomach,  Acute  Atony, 
Chronic  Atony,  Acute  Dilatation  of  the  Stomach,  Chronic 
Dilatation  of  the  Stomach 303 

Atony  of  the  Stomach 303 

Acute  Atony  of  the  Stomach 303 

Chronic  Atony  of  the  Stomach 304 

Acute  Dilatation  of  the  Stomach 306 

Chronic  Dilatation  of  the  Stomach 320 

Atonic  Dilatation  of  the  Stomach 322 

Obstructive  Type   (Stenotic)  of  Ectasia 325 

Diagnosis 326 

Treatment 329 

Treatment  of  Stenotic  Dilatation   (Benign  Stenosis) 335 

Treatment  of  Malignant  Stenosis 336 

Complications  of  Chronic  Ectasy 336 

Gastric  Tetany ' 336 

Convulsions,  Epilepsy 338 

CHAPTER    XVI 

Anomalies  in  the  Position  and  Form  op  the  Stomach,  Hour-glass 

Stomach,  Dislocations,  Gastroptosis 340 

Hour-glass  Stomach 340 

Dislocation  of  the  Stomach 341 

Gastroptosis,   Enteroptosis,  Glenard's  Disease 341 

CHAPTER   XVII 

Nervous  Affections  of  the  Stomach 359 

Sensory  Neuroses  of  the  Stomach 360 

Bulimia 360 

Parorexia   (Perversion  of  Appetite) 361 

Polyphagia 362 

Akoria 362 

Nervous  Anorexia   (Anorexia  Nervosa) 362 


12  CONTEXTS 

PAGE 

Nervous  Affections  of  the  Stomach:  Sensory  Neuroses  of  Stomach — 

Sensations  \\'ithin  the  Stomach 363 

Abnormal  Sensations 364 

Hyperesthesia  of  the  Stomach 364 

Gastralgia 365 

Gastralgokenosis  (Boasj 369 

Motor  Neuroses  of  the  Stomach 369 

HypermotUity  of  the  Stomach 369 

Peristaltic  Restlessness  of  the  Stomach  (Kussmaulj 370 

Antiperistaltic  Restlessness  of  the  Stomach 371 

Incontinence  of  the  Pylorus 371 

Spasm  of  the  Pylorus  (Pylorospasmus) 372 

Atony  of  the  Stomach 372 

Hypanakinesis  Ventriculi   (Einhorn) 372 

Hyperanakinesis  \'entriculi   (Einhorn) 373 

Spasm  of  the  Cardia  (Cardiospasmusj - 373 

Pyrosis   (Heart-burn) 375 

Regurgitation 37^ 

Rumination 376 

Nervous  Vomiting   (Vomitus  Nervosa) 377 

Periodic  Vomiting   (Von  Leyden) 378 

Cyclic  ^'omiting  in  Children 37^ 

Juvenile  Vomiting 379 

Reflex  Vomiting 379 

Idiopathic  Nervous  A'omiting 379 

Pneumatosis 380 

Secretory  Neuroses 380 

Nervous  Dyspepsia   (Leube) 381 

CHAPTER   XVIII 
Dyspeptic  Asthma 385 

CHAPTER  XIX 

The  Stomach  Functions  in  Diseases  of  Other  Organs 387 

Functions  of  the  Stomach  in  Acute  Febrile  Diseases 387 

Chronic  Febrile  Conditions 388 

Condition  of  the  Stomach  in  Pulmonary  Tuberculosis 388 

Chlorosis  and  Anemia 389 

Heart  Lesions 389 

Diseases  of  the  Liver 39° 

Aneurysm 390 

Diseases  of  the  Kidneys ■ 39° 

Diabetes 39° 

Arthritis  Deformans 39^ 

Gout : 391 

Malaria '• 39 ^ 

Diseases  of  the  Skin • 39^ 

Syphilis  of  the  Stomach 392 

Gastric  Ulcer  (Syphilitic) 393 

Syphilitic  Tumor  of  the  Stomach 393 

Syphilitic  Pyloric  Stenosis 393 

Syphilitic  Cirrhosis  of  the  Stomach 393 


CONTENTS  13 

Part  III 

DISEASES  OF  THE   INTESTINES 
CHAPTER   XX 

PAGE 

Methods  of  Examination  of  the   Intestines;   Examination  of  the 

Feces;  Mechanical  Procedures 394 

Physical  Examination  of  the  Intestines 395 

Inspection  of  the  Rectum — Proctoscopy  and  Sigmoidoscopy 396 

Transillumination  of   the  Intestines 404 

Inflation  of  the  Intestines  with  Carbonic  Acid  Gas  or  Air 406 

Lavage  of  the  Bowel  for   Diagnosis 408 

Examination  of  the  Feces 4^9 

Testing  the  Intestinal  Functions 420 

Mechanical  Procedures 428 

CHAPTER    XXI 

Diet,  Intestinal  Dyspepsia,  Indicanuria,  Saccharobutyric  Putre- 
faction, Botulism,  Hydrogen  Sulphid  Auto-intoxication, 
Enterogenic    Cyanosis,    Meteorism,    Enteralgia,    Visceral 

Arteriosclerosis,  Anomalies,  Intestinal  Sand 442 

Diet 442 

Intestinal   Dyspepsia 444 

Indicanuria 445 

Saccharobutyric  Type  of  Intestinal    Putrefaction 447 

Botulism 449 

Hydrogen  Sulphid   Auto-intoxication 449 

Enterogenic  Cyanosis 450 

Meteorism;  Tympanites 45 1 

Intestinal  Pain  (Intestinal  Colic,   Enteralgia)  . •  •  ■  453 

Visceral  Arteriosclerosis 455 

Anomalies  in  the  Position  and  Form  of  the  Intestines;  Enteroptosis.  .  456 

Intestinal  Sand 45^ 

CHAPTER   XXII 

Constipation  and  Diarrhea 458 

Constipation 45^ 

Diarrhea 47^ 

Diarrhea  Due  to  Irritation  of  the  Bowel  Contents 473 

Diarrhea  Due  to  Irritants  Transmitted  in  the  Blood 474 

Diarrhea  Nervosa   (Nervous  Diarrhea) 474 

Diarrhea  from  Exposure  to  Cold  and  Wet 475 

Treatment  of  Diarrhea 475 

CHAPTER    XXIII 

Intestinal  Catarrh,  Enteritis,  Colitis,  Catarrhal  Sigmoiditis,  Proc- 
titis, Phlegmonous  Enteritis 47^ 

Acute  and  Chronic  Intestinal  Catarrh 47^ 

Acute  Intestinal  Catarrh ■   478 

Chronic  Intestinal  Catarrh   (Chronic  Colitis) 4^7 

Proctitis 49S 

Phlegmonous  (Purulent)   Enteritis 500 


14  CONTENTS 

CHAPTER   XXIV  page 

Dysentery 501 

Diphtheritic  Dysentery 501 

Location 502 

Amebic  Dysentery 503 

Bacniary  Dysentery 520 

CHAPTER   XXV 

Typhoid  Fever 528 

CHAPTER   XXVI 

Intestinal  Hemorrhage,  Intestinal  Ulcers,  Diseases  of  the  Blood- 
vessels (Embolism  and  Thrombosis) 542 

Intestinal  Hemorrhage 542 

Ulcers  of  the  Intestines 543 

Simple  Duodenal   Ulc^r 543 

Intestinal   Ulcers  from  Cutaneous  Burns 546 

Embolic  and  Thrombotic  Ulcers 547 

Amyloid  Ulcers 547 

Tubercular  Ulcers  and  Intestinal  Tuberculosis 548 

Secondary  Tubercular  Ulcers  of  the  Intestines  (Tuberculosis)  .  549 

Catarrhal  and  Follicular  Ulcers 55° 

Ulcerative  Colitis 55° 

Stercoral  or  Decubital   Ulcers 55° 

Ulcers  in  Acute  Infectious  Diseases 55° 

Ulcers  in  Constitutional  Diseases 55° 

Toxic  Ulcers 55° 

Syphilitic,   Gonorrheal,   and  Cancerous  Ulcers 55 1 

Intestinal   Myiasis 55^ 

General   Symptoms  of  Intestinal   Ulceration 55 1 

Treatment -^^S 

Diseases  of  the   Blood-vessels;   Embolism   and  Thrombosis  of  the 

Mesenteric  Arteries  and  Veins  (Infarction  of  the  Bowel) 554 

CHAPTER    XXVII 

Neoplasms  of  the  Intestines • 559 

Malignant  Growths 559 

Carcinoma  of  the  Intestines 559 

Sarcoma  and   Lymphosarcoma  of    the  Intestines 57° 

Benign   Tumors   of   the   Intestines 57 1 

Gas  Cysts  of»the  Intestines 573 

CHAPTER  XXVIII 

Hemorrhoids,  Prolapse  of  Rectum,  Fissure 574 

Hemorrhoids 574 

CHAPTER   XXIX 

Appendicitis •" 59^ 


CONTENTS  15 
CHAPTER    XXX 

PAGE 

Diverticulitis,  Peridiverticulitis 620 

CHAPTER    XXXI 

Intestinal  Obstruction,  Acute  axd  Chronic 635 

Acute  Intestinal  Obstruction 635 

Chronic  Intestinal   Obstruction 657 

CHAPTER   XXXII 

Nervous  Diseases  of  the  Intestines 666 

Motor  Neuroses  of  the  Intestines 666 

Sensory  Neuroses  of  the  Intestines 669 

Secretory  Neuroses  of  the   Intestines 671 

Intestinal  Neurasthenia 671 

Mucous  Colic  (Membranous  Enteritis) 672 

CHAPTER    XXXIII 

Intestinal  Parasites 681 

Protozoa 68 1 

Amebse '. 681 

Sporozoa 681 

Intestinal  Psorospermiasis 681 

Infusoria 681 

Vermes 685 


Index 


DISEASES 

OF   THE 

STOMACH   AND    INTESTINES 


PART   I 


CHAPTER  I 
ANATOMY  OF  THE  STOMACH  AND  INTESTINES 

ANATOMY  OF  THE  STOMACH 

A  BRi^P  description  will  be  given  of  the  anatomy  of  the  stomach, 
but  for  a  complete  exposition  of  the  subject  the  reader  is  referred 
to  any  standard  anatomy. 

The  stomach  lies  in  the  epigastric  and  left  hypochondriac  regions, 
about  five-sixths  of  it  to  the  left  of  the  median  line.  The  larger  end, 
the  fundus,  fits  into  the  concave  left  vault  of  the  diaphragm.  It  is 
a  pyriform  sac,  with  longitudinal  diameter  slightly  oblique,  and 
lying  traUvSversely  across  the  abdomen  (Fig.  i). 

The  cardiac  orifice  (C),  the  junction  of  the  esophagus  and  stomach 
(the  esophageal  orifice),  is  fixed  and  lies  behind  or  a  little  to  the  left 
of  the  sternal  junction  of  the  left  seventh  cartilage  (seventh  rib),  or 
about  1 1  inches  from  the  edge  of  the  sternum,  in  the  left  parasternal 
line,  on  a  level  with  the  spinous  process  of  the  ninth  dorsal  vertebra. 
The  cardia  is  situated  ^.h  inches  from  the  anterior  surface  of  the 
abdomen.  The  point  of  communication  with  the  small  intestine 
is  called  the  pylorus  (P),  and  shows  a  furrow  on  the  outer  surface  and 
within  a  protruding  fold  (the  valve  of  the  pylorus). 

The  pylorus  (P)  lies  between  the  right  sternal  and  parasternal 
lines,  slightly  below  the  tip  of  the  ensiform  process,  and  corresponds 
to  the  spinous  process  of  the  twelfth  dorsal  vertebra.  It  descends 
slightly  when  the  stomach  is  distended  and  moves  somewhat  to  the 
right.  A  line  (-f ),  drawn  in  the  axis  of  the  esophagus  through  the 
stomach  to  its  lower  border,  cuts  off  about  one-fourth  of  the  organ 
to  the  left.     This  portion  is  called  the  greater  cul-de-sac  or  fundus  (/-"). 

The  fundus  (F)  rises  as  high  as  the  lower  border  of  the  left  fifth 
rib  in  the  mammillary  line,  slightly  above  and  behind  the  apex  of 
the  heart,  and  from  i  to  2  inches  higher  than  the  cardia.  It  is  in 
contact  with  the  diaphragm  above,  and  to  the  left  with  the  spleen 
and  left  kidney. 


i8 


DISEASES    OF    THE    STOMACH    AND   INTESTINES 


The  lesser  curvature  (L)  lies  to  the  left  of  the  vertebral  column, 
passes  downward  and  parallel  with  it,  and  then  crosses  it  to  the 
upper  border  of  the  pylorus. 

The  greater  curvature  (G)  forms  the  fundus  and  lower  border  of 
the  stomach  and  extends  to  the  lower  border  of  the  pylorus.  The 
lower  border,  when  the  organ  is  distended,  lies  about  two  to  three 
fingers'  breadth  (i^  to  2|  inches)  above  the  umbilicus. 


Fig.   I. — The  stomach:   C,  Cardia;  F,  fundus;   P,  pylorus;   L,  lesser  curvature; 
G,  greater  curvature  (modified  from  W.  J.  Mayo). 


The  volume  of  the  stomach  varies  according  to  its  contents. 
Dehio  has  shown  that  the  healthy  stomach  when  empty  is  contracted 
and  hidden  away  in  the  left  cavity  of  the  diaphragm,  and  it  is  the 
colon  that  we  then  demonstrate  by  percussion. 

The  pancreas  and  splenic  vessels  lie  behind  the  stomach.  The 
anterior  surface  is  overlapped  above  by  the  liver,  the  left  lung,  and 
the  seventh,  eighth,  and  ninth  ribs.  Below  it  is  in  relation  with  the 
abdominal  wall. 


ANATOMY    OF    THE    STOMACH    AND    INTESTINES 


19 


The  pyloric  end,  the  lesser  curvature,  and  the  cardia  lie  behind 
and  beneath  the  quadrate  and  left  lobes  of  the  liver. 

Traube's  space  is  the  area  in  which  the  stomach  lies  in  direct 
contact  with  the  ribs,  and  is  bounded  above  by  the  liver  and  left 
lung,  externally  by  the  spleen,  and  the  inner  border  is  formed  by 
the  free  costal  margin.  Both  here  and  in  the  epigastric  region  pure 
gastric  tympany  can  be  elicited. 

When  the  stomach  is  distended,  the  lesser  curvature  is  directed 
obliquely  backward  toward  the  spine,  the  posterior  wall  looking 
somewhat  downward  and  the  anterior  wall  slightly  upward.  The 
transverse  colon,  if  distended,  may  overlap  the  greater  curvature, 
and  the  latter  tends  to  fall  away  from  the  abdominal  wall  when  the 
patient  is  in  the  dorsal  position.  The  transverse  colon  lies  ordinarily 
below  the  greater  curvature.  With  moderate  distention,  the  average 
length  from  fundus  to  pylorus  is  10  to  12  inches;  from  the  lesser  to 
greater  curvature,  4  to  5  inches; 
from  the  anterior  to  the  posterior 
wall,  about  3  to  3  J  inches. 

The  average  capacity  is  vari- 
able. It  may  contain  even  as 
much  as  2  quarts.  A  plane 
drawn  transversely  through  the 
base  of  the  lesser  curvature  will 
lie  parallel  with  the  plane  of  the 
diaphragm. 

The  lesser  omentum  extends 
from  the  lesser  curvature  to  the 
liver  above,  and  the  great  omen- 
tum is  suspended  from  the  greater 
curvature,  protecting  the  viscera. 

The  blood-vessels  enter  the 
upper  and  lower  borders,  and 
thus  divide  the  surface  into  two 
equal  parts.  They  mark  the 
greater  and  lesser  curvatures. 

Structure  of  the  Stomach. — 
The  stomach  consists  of  four 
coats:  serous  or  peritoneal,  mus- 
cular, submucous  or  areolar,  and 
mucous.  The  peritoneal  coat 
forms  a  thin,  transparent,  elastic 

membrane,  and  closely  covers  the  organ  except  along  the  curvatures, 
where  it  is  more  loosely  attached  for  the  passage  of  the  blood-vessels. 

The  muscular  coat  consists  of  three  sets  of  fibers  (Fig.  2),  dis- 
posed in  layers,  the  outer  or  longitudinal,  middle  or  circular,  and 
inner  or  oblique.  The  last  is  a  continuation  of  the  circular  fibers 
of  the  esophagus  and  the  fibers  descend  obliquely  from  the  cardia 


Fig.  2. — Vertical  sttii'Mi  of  the 
stomach:  i.  Mucosa;  2,  submucosa; 
3,  4,  muscuiaris;  5,  serosa. 


20  DISEASES    OF   THE    STOMACH    AND    INTESTINES 

upon  the  anterior  and  posterior  surface,  and,  spreading  out  like  a 
fan,  terminate  at  the  greater  curvature. 

The  submucous  coat  consists  of  areolar  tissue,  connecting  the 
mucous  and  muscular  coats.     The  blood-vessels  subdivide  therein. 

The  mucous  membrane  is  soft,  smooth,  somewhat  pulpy,  and 
of  pink  color,  thickest  in  the  pyloric  region  and  thinnest  at  the 
fundus.  It  constitutes  the  glandular  layer  of  the  organ.  It  is 
covered  by  columnar  epithelial  cells,  which  extend  for  a  variable 
distance  into  the  mouths  of  the  glands.  There  are  about  five  million 
glands  in  the  stomach,  tubular  in  form,  and  perpendicular  to  the 
surface.  They  are  surrounded  by  fibrous  tissue  and  lymphoid  cells 
and  by  a  thin  muscle  layer  (muscularis  mucosae). 

The  glands  are  composed  of  a  mouth,  neck,  body,  and  base;  and 
several  tubules,  from  two  to  even  four  or  five,  may  end  in  one  mouth. 
On  microscopic  examination,  the  dots  appearing  on  the  surface  of 
the  mucosa  are  the  openings  of  the  glands.  There  are  three  varieties 
of  glands  in  the  stomach: 

Cardiac  or  fundus  glands.     Pyloric  glands.     Mucous  glands. 

Cardiac  or  fundus  glands  are  the  most  numerous.  They  fill  the 
greater  part  of  the  stomach  and  are  characterized  by  the  shortness 
of  their  mouths  and  the  length  of  the  glands.  They  contain  two 
varieties  of  cells.  Cells  bordering  on  the  lumen  of  the  tube,  which 
are  small,  granular,  and  pol3^hedral  or  columnar,  the  chief  or  principal 
cells,  and'  which  only  stain  to  a  slight  extent  with  anilin  dyes.  The 
other  cells,  parietal  or  oxvntic,  lie  between  the  principal  cells  and 
the  membrana  propria  (Fig.  3).  They  are  most  numerous  in  the 
necks  of  the  glands,  larger  than  the  chief  cells,  are  oval  or  angular 
and  finely  granular  in  structure.  The}^  have  strong  affinity  for 
anilin  dyes. 

Pyloric  Glands. — These  are  characterized  by  the  greater  length 
of  their  mouths,  which  are  lined  b}'  cylindric  epithelium.  They  are 
found  only  in  the  region  of  the  pylorus.  The  body  or  secretory 
portion  of  the  gland  is  represented  b}^  a  single  layer  of  short  and 
finely  granular  colunmar  cells,  resembling  the  chief  cells  of  the  fundus 
glands.  There  are  also  a  few  isolated  cells  (Nussbaum)  which 
resemble,  in  structure  and  in  their  behavior  to  anilin  dyes,  the  parietal 
cells  of  the  fundus  glands  (Fig.  4). 

Besides  these  specific  glands,  a  number  of  vmcous  glands  are 
found  near  the  pylorus. 

The  hydrochloric  acid  is  secreted  by  the  parietal  cells;  pepsin 
and  the  milk-curdling  ferment  by  the  principal  cells  of  the  fundus 
and  pyloric  glands.  Some  consider  the  mucus  to  be  also  a  product 
of  the  cylindric  goblet-cells  lining  the  stomach  and  the  wider  portions 
of  the  glandular  ducts.  The  ferments  do  not  exist  as  such  in  the 
cells,  but  as  zymogens,  which  are  transformed  into  ferments  through 
the  activity  of  the  free  hydrochloric  acid. 

Blood-vessels ,    Lymphatics,    and    Nerves    of    the    Stomach. — The 


ANATOMY    OF    THE    STOMACH    AND    INTESTINES 


arteries  of  the  stomach  are  derived  from  branches  of  the  ceUac  axis; 
the  gastric  and  pyloric  branch  of  the  hepatic  artery  supplying  the 
upper  curvature  and  forming  the  superior  ventricular  arch  and  the 
right  gastro-epiploic  from  the  hepatic,  and  the  left  gastro-epiploic 
and  vasa  brevia  from  the  splenic  form  the  inferior  ventricular  arch. 
They  reach  the  stomach  between  the  folds  of  peritoneum  and 
ramify  between  the  muscular  coats,  giving  oflF  a  number  of  capillaries 
and  dividing  into  small  vessels  in  the  submucosa,  and  finally  enter 
the  mucous  membrane,  and  pass  between  the  tubuli,  where  they 


/ 


\»^SSi 


Fig.  3. — Cardiac  gland:  o,  Parietal 
cells;  b,  principal  cells. 


Fig.  4. — Pyloric  gland :  a,  Mouth;  h, 
neck;  c,  fundus. 


form  a  plexus  of  fine  capillaries  both  on  the  walls  of  the  tubules  and 
around  the  mouths  of  the  glands. 

The  veins  arise  from  this  capillary  network  and  pass  nearl\- 
straight  through  the  mucous  membrane  between  the  glands.  The> 
pierce  the  muscularis  mucosae  and  form  a  plexus  in  the  submucosa. 
and  finally  form  the  coronary  and  pyloric  veins  empt>-ing  into  the 
portal  vein,  the  right  gastro-epiploic  vein  emptying  into  the  superior 
mesenteric  vein,  and  the  left  gastro-epiploic  vein  emptying  into  the 
splenic  vein. 

The  lymphatics  extend  directly  to  the  surface  of  the  mucosa. 
They  form  a  dense  network  of  lacunar  spaces  between  and  among 


22  DISEASES    OF   THE    STOMACH    AND    INTESTINES 

the  gland  tubuli,  which  they  enclose,  as  well  as  the  blood-vessels, 
with  sinus-like  dilatations.  The  lymph  is  collected  near  the  surface 
of  the  mucous  membrane  into  vessels  which  form  loops  and  possess 
dilated  extremities.  They  are  less  superficial  than  the  capillaries, 
though  the  lacunar  spaces  extend  as  far  as  the  basement-membrane 
of  the  surface.  The  lymphatic  glands  extend  along  the  lesser  curva- 
ture to  the  cardia,  while  they  are  present  on  the  greater  curvature 
from  the  pylorus  to  only  about  one- fourth  to  one-third  of  the  distance. 
This  fact  is  of  important  consideration  in  gastrectomy  for  carcinoma, 
as  the  lesser  curvature  must,  therefore,  be  entirely  removed. 

Nerves. — The  left  vagus  supplies  the  anterior  surface  of  the 
stomach.  The  right  vagus  supplies  the  posterior  surface  with  only 
one-third  of  its  fibers,  the  remainder  passing  to  the  other  viscera. 

Branches  of  the  S3^mpathetic  nerves  pass  from  the  celiac  plexus 
and  anastomose  with  the  vagi.  These  nen,^es  with  numerous  ganglia 
form  a  network  in  the  submucosa. 

ANATOMY  OF  THE  INTESTINES 

The  intestinal  canal  is  divided  into  two  parts :  the  small  intestine 
and  the  large  intestine;  the  former  about  7.6  meters  (25  feet)  long, 
and  the  latter  1.5  to  1.8  meters  (5-6  feet)  long. 

The  small  intestine  is  subdivided  into  three  portions:  the  duo- 
denum, jejunum,  and  ileum,  and  lies,  excepting  the  duodenum,  to 
the  inner  side  of  the  large  intestine,  and  is  connected  to  the  posterior 
abdominal  wall  by  the  mesenter}^,  which  last  encloses  the  jejunum 
and  ileum  throughout. 

The  Duodenum. — The  duodenum,  which  is  about  10  to  12  inches 
(25.5-30.5  cm.)  long,  is  not  suspended  by  the  mesentery  and  is  the 
most  fixed  and  widest  part  of  the  small  intestine,  having  a  diameter 
of  1 1  to  2  inches  (3.81-5.08  cm.).  It  is  curved  like  a  horseshoe, 
surrounds  the  pancreas,  and  is  divided  into  four  parts  (Fig.  5). 

The  superior  horizontal  part  of  the  duodenum  is  about  2  inches 
(5.08  cm.)  long,  begins  at  the  pylorus  at  the  level  of  the  first  lumbar 
vertebra,  and  passes  slightly  upward  and  to  the  right  of  the  gall- 
bladder. It  is  the  most  movable  portion,  is  surrounded  by  the 
peritoneum,  and  suspended  chiefly  by  ligaments  from  the  hilus  of 
the  liver  and  neck  of  the  gall-bladder.  The  quadrate  lobe  and  neck 
of  the  gall-bladder  lie  above  it ;  below  it  is  the  pancreas,  and  behind 
it  the  common  bile-duct  and  hepatic  vessels. 

The  descending  portion  of  the  duodenum,  about  3  inches  (7.5  cm.) 
long,  commences  at  the  neck  of  the  gall-bladder  and  runs  vertically 
to  the  third  or  fourth  lumbar  vertebra  on  the  right  side  and  touches 
the  right  kidney.  The  transverse  colon  passes  in  front  of  it ;  on  the 
left  side  is  the  pancreas,  and  the  common  bile-duct  lies  a  little  poste- 
rior. At  its  inner  and  back  part,  about  4  inches  from  the  pylorus,  the 
common  bile-duct  and  pancreatic  duct  enter  it  and  form  the  diverticu- 
lum or  ampulla  of  Vater. 


ANATOMY    OF    THE    STOMACH    AND    INTESTINES 


23 


The  third  or  transverse  portion  of  the  duodenum,  about  5  inches 
(12.5  cm.)  long,  extends  from  the  right  side  of  the  body  of  the  third 
or  fourth  lumbar  vertebra  across  the  spine,  and  slightly  ascends  to 
the  left  side  of  the  spine.  The  superior  mesenteric  vessels  cross  it, 
as  does  the  mesentery.  The  lower  layer  of  transverse  mesocolon 
lies  in  front.  The  pancreas  and  superior  mesenteric  artery  lie  above, 
and  the  aorta,  vena  cava,  and  crura  of  the  diaphragm  behind  it. 
It  is  the  most  fixed  portion  of  the  duodenum. 


Fig.   5. — Stomach  and  duodenum,  liver  and   intestines  removed,  and   showing 
anatomic  relations  of  the  duodenum  (after  Testut). 


The  fourth  or  ascending  portion  of  the  duodenum,  about  i  to  2 
inches  (2.54-5.08  cm.)  long,  ascends  vertically  along  the  left  side  of 
the  spine  from  the  third  or  fourth  lumbar  vertebra  to  the  side  of  the 
second  or  first  lumbar  vertebra.  It  is  firmly  fixed  by  the  suspensory 
muscle  of  the  duodenum  (muscle  of  Treitz),  which  descends  from 
the  left  crus  of  the  diaphragm.  Anteriorly  are  the  transverse  colon 
and  transverse  mesocolon  (lower  layer).  It  terminates  in  the  jejunum 
(usually  opposite  the  second  lumbar  vertebra)  and  forms  the  duodeno- 
jejunal flexure. 

Jejunum    and    Ileum. — They    form    the    continuation    of    the 


24  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

duodenum.  It  is  hard  to  determine  where  the  one  ends  and  the 
other  begins.  The  jejunum  occupies  the  upper  two-fifths  of  the 
remaining  small  intestines,  or  about  9  feet,  7  inches  (2.9  meters) ; 
the  ileum  the  lower  three-fifths,  or  about  14  feet,  5  inches  (4.3  meters), 
and  ends  at  the  ileocecal  junction.  Their  position  is  not  fixed,  but 
the  jejunum  is  more  apt  to  occupy  the  left  side  of  the  abdominal 
cavity,  with  the  loops  more  transverse;  while  the  ileum  is  usually 
found  on  the  right  side  and  in  the  pelvis,  with  the  loops  more  vertical. 

The  coils  of  the  jejunum  and  ileum  are  very  movable  and  are 
completely  invested  by  peritoneum.  They  are  supported  and 
attached  to  the  posterior  parietes  by  the  mesentery,  w'hich  is  attached 
above  to  the  left  of  the  vertebrae  on  a  level  with  the  lower  border  of 
the  pancreas.  The  mesentery  runs  downward  and  to  the  right  and 
presents  the  form  of  a  fan,  the  intestines  hanging  on  it  in  the  form 
of  coils. 

The  diameter  of  the  jejunum  is  about  ij  inches  (3.81  cm.),  and 
this  gradually  diminishes  in  size  to  the  ileum;  and  in  this,  in  turn, 
the  diameter  decreases  until  its  entrance  into  the  large  intestine. 
The  ileum  passes  nearly  perpendicularly  into  the  ascending  colon, 
its  mucosa  forming  a  double  valve  (valvula  Bauhini). 

The  jejunum  and  ileum  are  the  most  movable  parts  of  the  intes- 
tinal tract.  They  are  often  met  with  in  hernias,  and  if  pregnancy, 
a  tumor,  or  ascites  are  present,  the  intestines  move  up  and  escape 
compression. 

Occasionally  Meckel's  diverticulum  (the  remains  of  the  vitelline 
duct),  a  process  2  or  3  inches  long,  is  given  off  from  the  ileum,  on  an 
average  of  i  to  2  feet  above  the  ileocecal  junction.  It  is  of  import- 
ance in  reference  to  intestinal  obstruction. 

Arterial  Supply  of  Small  Intesti'ne. — The  duodenum  is 
supplied  by  the  pyloric  branch  of  the  hepatic,  by  the  superior  pan- 
creaticoduodenal branch  of  the  gastroduodenal  branch  of  the  hepatic 
and  by  the  inferior  pancreaticoduodenal  branch  of  the  superior 
mesenteric,  and  the  jejunum  and  ileum  by  the  superior  mesenteric 
artery.  They  branch  into  small  vessels  which  run  through  the 
intestinal  wall,  ramify  in  the  submucosa,  and  form  the  capillary 
system  of  the  villi  and  glands. 

Veins. — The  venous  blood  flows  partly  into  the  superior  gastric 
vein  and  partly  into  the  superior  mesenteric  vein  and  empties  into 
the  vena  porta. 

Lymphatics. — The  lymphatics  are  divided  into  those  of  the 
mucous  membrane  and  muscular  coat,  and  form  plexuses.  They 
run  between  the  folds  of  the  mesentery  and  end  in  the  mesenteric 
lacteals,  and  so  on  into  the  intestinal  lymphatic  trunk  and  thoracic 
duct.     They  are  provided  with  valves  to  prevent  a  backward  flow. 

Nerves. — The  duodenum  is  supplied  by  the  hepatic  plexus,  a 
branch  of  the  celiac  plexus,  with  branches  of  the  right  vagus. 

The    superior   mesenteric    plexus,    formed   by   nerves   from    the 


ANATOMY    OF    THE    STOMACH    AND    INTESTINES 


25 


celiac  plexus,  the  semilunar  ganglia,  and  right  vagus,  supph-  the 
jejunum  and  ileum. 

The  nerves  enter  the  intestinal  wall  with  the  blood-vessels  and 
form  a  subserous  net.  They  then  penetrate  the  longitudinal  muscu- 
lar fibers  and  form  between  these  and  the  circular  muscular  fibers 
ramifications  consisting  of  numerous  groups  of  multipolar  cells 
(Auerbach's  plexus),  from  which  fine  branches  supply  the  muscular 
tissue.  Other  branches  penetrate  the  circular  muscular  layer  to  the 
submucosa,  where  they  form  the  submucous  nerve  plexus  (Meissner's 
plexus),  and  branches  supply  the  muscularis  mucosae,  the  muscles 
of  the  villi,  and  end  in  the  mucosa. 

Structure  of  the  Small  Intestine. — The  small  intestine  is 
composed  of  four  coats :  serous  or  peritoneal,  muscular,  submucous, 
and  mucous  (Fig.  6). 


Fig.  6. — Longitudinal  cross-section  through  the  wall  of  the  small  intestine: 
I,  Mucous  layer;  2,  muscularis  mucosae;  3,  submucous  layer;  4,  muscular  layer; 
5,  subserosa;  6,  serous  layer;  7,  intestinal  villi;  8,  intestinal  glands  (Lieber- 
ktihn);  9,  blood-vessels;   10,  solitary  lymph  nodule;   11,  center  of  same. 


The  serous  coat  is  formed  by  the  visceral  layer  of  the  peritoneum. 
The  muscular  coat  consists  of  an  internal  circular  layer  and  an 
external  longitudinal  layer,  the  former  being  considerably  the  thicker. 

They  consist  of  bundles  of  unstriped  muscular  tissue  supported 
by  connective-tissue  fibers.  The  submucosa  consists  of  connective 
tissue  in  which  blood-vessels,  lymphatics,  and  nerves  ramify. 

The  mucous  membrane  comprises  a  thin  muscular  layer  (muscu- 
laris mucosae),  containing  circular  and  longitudinal  fibers  and  the 
tunica  propria  of  the  mucous  membrane,  which  is  made  up  principally 
of  reticular  connective  tissue,  with  leukocytes,  glands,  villi,  and  an 
epithelial  covering. 

The  mucosa  is  of  a  grayish-red  color,  appears  velvety,  and  forms 
crescentic  folds,  set  transversely  to  the  long  axis  of  the  intestine 
(valvulae  conniventes  of  Kerkring,  Fig.  7).  Each  valve  extends 
from  one-half  to  two-thirds  of  the  circumference  of  the  gut,  and  they 
may  be  2  inches  long  and  }  inch  wide.  They  begin  a  short  distance 
below  the  pylorus,  at  the  middle  of  the  jejunum  commence  to  diminish 


26 


DISEASES   OF   THE    STOMACH   AND    INTESTINES 


in  size,  and  gradually  disappear  at  the  lower  part  of  the  ileum.     They 
serve  to  increase  the  absorptive  surface  of  the  mucous  membrane. 


muscular  coat 


mesentery  x 


Tular  folds 
(+  intestinal  villi) 

Fig.   7. — A  portion  of  the  jejunum  showing  the  circular  folds  or  valvulae  con- 
niventes  of  Kerkring  (Sobotta). 

Microscopic    Anatomy    of   the    Small    Intestine. — The   inner 
surface  of  the  small  intestine  is  composed  of  villi  and  glands,  the 

surface  being  covered  by  a  layer 
of  columnar  epithelial  cells,  with 
striated  borders  and  some  goblet- 
cells. 

The  villi  are  formed  chiefly  by 
elevations  of  the  tunica  propria  of 
the  mucous  membrane.  They  are 
from  .5  to  .7  mm.  in  height  and  about 
.1  to  .2  mm.  in  width,  and  number 
about  ten  millions  (Fig.  8). 

Each  villus  has  a  central  space 
for  chyle,  which  cavity  is  covered 
with  endothelial  cells  and  connects 
with  the  lymphatics  of  the  mucosa. 
The  villus  has  blood-vessels  and 
muscular  fibers  which  are  derived 
from  the  muscularis  mucosae.  It  expands  when  filling  up  with  blood, 
and  when  the  muscle  contracts  it  shrinks. 


Fig. 
ileum; 


—Mucous  membrane  of 
Intestinal  glands  (Lie- 
berkiihn);  b,  intestinal  villi;  c, 
solitary  lymph  nodule  (follicle) . 


ANATOMY   OP   THE    STOMACH    AND    INTESTINES 


27 


The  villi  thus  have  an  action  of  suction  and  pumping,  and  also 
form  the  chief  organs  for  absorption  in  the  small  intestine.  Around 
the  villi  are  numerous  glands;  the  tubular  glands  of  Lieberkiihn  and 
the  acinous  glands  of  Brunner.  The  latter  are  confined  to  the 
duodenum. 

The  glands  of  Lieberkiihn  resemble  in  structure  the  tubular 
glands  of  the  stomach,  and  cover  almost  the  entire  surface  of  the 
small  and  large  intestine.  Each  tubule  is  from  .3  to  .4  mm.  long, 
and  opens  without  ramifications.  They  form  the  chief  organ  of 
intestinal  secretion  and  number  over  forty  millions. 

Brunner's  glands  are  found  only  in  the  duodenum  and  are  most 
abundant  at  its  commencement,  diminishing  in  number  lower  down. 
They  He  beneath  the  mucosa,  being  embedded  in  the  submucosa. 
They  resemble  the  pyloric  glands  of  the  stomach,   but  are  more 


Fig.  9. — Longitudinal  cross-section  through  wall  of  duodenum:  i,  Mucous 
layer;  2,  muscularis  mucosae;  3,  submucous  layer;  4,  circular  muscular  layer; 
5,  longitudinal  muscular  layer;  6,  intestinal  villi;  7,  intestinal  glands  (Lieber- 
kiihn); 8,  Brunner's  duodenal  glands;  9,  serous  layer. 

branched  and  convoluted,  and  their  ducts  are  longer.  They  are 
lined  with  columnar  epitheHum.  The  duct  of  the  gland  passes 
through  the  muscularis  mucosae  and  opens  on  the  surface  of  the 
mucosa  (Fig.  9). 

Solitary  follicles  (or  glands)  are  scattered  throughout  the  mucous 
membrane  of  the  small  intestine  and  are  most  numerous  in  the  lower 
ileum.     They  have  a  diameter  of  2  to  6  mm.  (Fig-  10). 

The  follicles  consist  of  a  dense  retiform  tissue  packed  with  lymph- 
corpuscles  and  permeated  by  capillaries.  They  have  no  ducts.  The 
spaces  in  this  tissue  are  continuous  with  lymph-spaces  at  the  base 
of  the  gland  and  the  base  of  the  follicle  is  in  the  submucous  tissue. 
The  gland  enters  the  mucous  membrane,  causing  a  slight  projection 
of  its  epithelial  layer.  Lvmph-cells  develop  in  these  follicles.  There 
are  no  villi  on  their  surface. 


28 


DISEASES   OF   THE   STOMACH   AND   INTESTINES 


These   follicles    are    scattered    singly   through    the   intestine   as 
solitary  glands,  or  collected  into  groups,  known  as  Peyer's  patches  or 


mesentery  x 


'''■i''  circular  folds 

solitary  lymphatic  nodules 

Fig.  lo. — A  portion  of  the  ileum  showing  solitary  lymphatic  nodes  (Sobotta). 


■-K  circular 
^folds 


^'---i^nrj:" 


aggregated  lymphatic  nodules     mesentery  x 
■    (Peyer's  patch) 

Fig.  II. — A  portion  of  the  ileum,  cut  open  along  the  line  of  attachment  of  the 
mesentery,  showing  Peyer's  patch  and  solitary  lymphatic  nodes  (a)  (Sobotta"). 


plaques,  or  as  the  agminate  glands.     These  last  may  be  from  i  to  3 
inches  long  and  h  inch  wide,  usually  oval,  with  the  long  axis  parallel 


ANATOMY    OF    THE    STOMACH    AND    INTESTINES 


29 


with  that  of  the  intestine.  They  He  generally  opposite  the  attach- 
ment of  the  mesentery,  are  twenty  to  thirty  in  number,  and  are  found 
chiefly  in  the  ileum,  though  a  few  are  present  in  the  jejunum  (Fig.  u). 
Anatomy  of  the  Large  Intestine. — The  large  intestine,  which 
is  about  5  to  6  feet  (1.5 -1.8  meters)  long,  extends  from  the  termina- 
tion of  the  ileum  to  the  anus,  and  is  divided  into  the  cecum  (or  caput 
coli) ,  the  colon,  and  the  rectum.  Its  caliber  is  largest  at  the  cecum, 
and  this  gradually  decreases  until  it  reaches  the  ampulla  of  the 
rectum,  when  it  again  increases  in  size. 


Fig.  12. — Partial  section  of  colon:    1,  Free  tenia;   2,  tenia  mesocolica;   3,  appen- 
dices epiploicae;  4,  mucosa;  5,  semilunar  folds;  6,  mesocolon.- 


The  large  intestine,  excepting  the  rectum,  is  characterized  by 
three  longitudinal  unstriated  muscular  bands  or  teniae  (Fig.  1^2), 
with  sacculation  of  the  walls  between  these  bands  and  by  the  appen- 
dices epiploic^,  or  external  pouches  formed  by  the  peritoneal  covering 
and  containing  fat. 

The  circular  muscular  fibers  also  accumulate  in  bands  with 
intervals  between  them,  thus  forming  expansions  or  semilunar  folds 
across  the  colon  (haustra  coli)  (I'ig.  13). 

The  cecum  (caput  coli)  is  that  part  of  the  colon  lying  below  the 
ileocecal  valve  (Fig.  14).     It  is  about  3  inches  (7.5  cm.)  broad  and 


30 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


2§  inches  (6.3  cm)  long,  and  lies  in  the  right  iliac  fossa  above  the 
outer    half    of    Poupart's    ligament,    being   completely    covered    by 

semilunar  folds 


lumen 

omental  __ 
band  ~ 


'free  band 
Fig.  13. — A  segment  of  the  colon  (Sobotta) ;  Haastra  coli. 

peritoneum.     When  filled,  it  is  situated  close  to  the  abdominal  wall. 
The  vermiform  appendix,  a  small  blind  tube,  hollow  nearly  to  the 


free  band        ascending  colon 


post, 
frenulum  of  valve. 


upper  lip  of  valve.. 


semilunar  folds 


lower  lip  of  valve 


vermiform  process 
Fig.  14. — The  cavity  of  the  cecum  (SobottaV 

tip,  is  given  off  generally  from  the  posterior  and  inner  portion  of 
the  caput  coH,  about  \\  inch  (1.7  cm.)  below  the  ileocecal  valve. 


ANATOMY    OF    THE    STOMACH    AND    INTESTINES  3 1 

Its  average  length  is  3^^  inches  (9.2  cm.).  It  may  be  much  shorter 
or  longer.  The  diameter  is  about  \  inch  (6  mm.)  at  base  and  y^^  inch 
(5  mm.)  at  apex.  It  may  be  slightly  larger  at  the  middle.  It  is 
usually  guarded  by  a  valve  (crescentic  fold)  where  it  enters  the 
cecum.  It  has  a  meso-appendix  (mesentery)  only  extending  about 
two-thirds  its  length.  The  position  of  the  appendix  is  not  fixed  and 
it  may  point  in  various  directions.     The  colon  is  depicted  in  Fig.  2 1 . 

The  ascending  colon,  about  8  inches  (20  cm.)  in  length,  extends 
vertically  upward  from  the  cecum  to  the  inferior  surface  of  the  right 
lobe  of  the  Hver  to  the  right  of  the  gall-bladder,  at  which  point  it 
bends  to  the  left  (hepatic  flexure).  It  passes  along  the  posterior 
abdominal  muscles  and  lower  part  of  the  right  kidney,  and  is  in 
relation  to  the  abdominal  wall  in  front.  It  is  bound  posteriorly  by 
connective  tissue  to  the  muscles,  and  is  only  covered  by  peritoneum 
anteriorly  and  laterally. 

The  transverse  colon,  with  an  average  length  of  20  inches  (51  cm.), 
extends  from  the  hepatic  flexure  beneath  the  liver  transversely 
across  the  abdominal  wall,  with  a  slightly  downward  and  forward 
convexity  at  its  center,  to  the  spleen  in  the  left  hypochondrium 
(splenic  flexure).  It  has  a  long  mesentery,  transverse  mesocolon, 
connecting  it  with  the  posterior  abdominal  wall,  and  is  the  most 
movable  part  of  the  large  intestine.  It  usually  corresponds  to  a  line 
separating  the  umbilical  and  epigastric  regions.  The  liver,  gall- 
bladder, greater  curvature  of  the  stomach,  and  lower  end  of  the 
spleen  lie  above  it;  the  small  intestine  lies  below;  the  descending 
duodenum  and  small  intestine  behind;  the  great  omentum  and 
abdominal  wall  in  front. 

At  the  splenic  flexure  below  the  lower  end  of  the  spleen,  the  colon 
turns  downward  (descending  colon).  This  is  about  8^  inches 
(21.5  cm.)  long,  and  extends  from  the  splenic  flexure  vertically 
through  the  left  hypochondriac  and  lumbar  regions  to  the  sigmoid 
flexure.  It  is  covered  anteriorly  and  laterally  by  the  peritoneum, 
and  passes  down  in  front  of  the  left  kidney  and  quadratus  lumborum 
and  iliac  muscles,  to  the  left  iUac  fossa  into  the  sigmoid  flexure. 

The  sigmoid  flexure  of  the  colon  (S.  romanum)  is  an  S-shaped 
curve,  about  13  inches  (31  cm.)  long,  beginning  at  the  iliac  crest  and 
ending  at  the  brim  of  the  true  pelvis  opposite  the  left  sacro-iliac 
articulation.  The  upper,  or  colic,  limb  tends  down,  inward,  and 
forward  toward  Poupart's  ligament,  while  the  lower,  or  rectal,  limb 
hangs  down  into  the  true  pelvis,  where  it  joins  the  rectum.  The 
sigmoid  flexure  has  a  complete  peritoneal  covering,  or  mesentery, 
is  very  movable,  and  is  the  narrowest  portion  of  the  large  intestine. 

The  rectum,  which  is  about  8  to  9  inches  (20-23  cm.)  long,  passes 
from  the  left  sacro-iliac  junction  obliquely  to  the  middle  of  the 
sacrum,  and  follows  it  down  to  the  bottom  of  the  pelvis  to  about 
I  inch  (2.5  cm.)  below  the  tip  of  the  coccyx,  where  it  passes  downward 
and  backward  to  end  in  the  anus.     It  is  divided  into  three  portions. 


32  DISKASES   OF   THE    STOMACH   AND   INTESTINES 

Only  the  first  part,  35  inches  (9  cm.),  of  the  rectum  is  completely- 
invested  with  peritoneum  (mesorectum) ,  and  it  is  attached  to  the 
sacral  vertebrae.  The  second  part  is  partially  invested  with  peri- 
toneum (pouch  of  Douglas),  which  lies  anterior  and  ascends  over  the 
bladder  or  vagina.     The  third  part  has  no  peritoneal  investment. 

The  lower  half  of  the  rectum  passes  between  the  organs  occupying 
the  pelvic  floor  and  is  adherent  to  them  by  connective  tissue.  The 
rectum  is  surrounded  by  connective  tissue  below  the  pouch  of  Douglas. 
It  is  widest  at  the  point  opposite  the  prostate,  there  forming  the 
ampulla  of  the  rectum. 

The  outer  longitudinal  muscular  fibers  of  the  rectum  are  not 
arranged  in  teniae,  as  in  the  colon,  but  are  present  in  all  parts  of  its 
circumference.  The  inner  circular  layer  of  muscle-fibers  increases  in 
density  from  above  downward  and  forms  a  thick  ring  at  the  anal 
opening  (the  internal  sphincter).  The  w^alls  of  the  rectum  are 
connected  at  the  anus  with  the  sphincter  ani  and  levator  ani  muscles, 
which  are  of  importance  in  defecation. 

Arterial  Supply  of  the  Cecum  and  Colon. — They  are  the 
ileocolic,  colica  dextra,  and  colica  media  from  the  superior  mesenteric 
artery;  the  colica  sinistra  and  sigmoid  from  the  inferior  mesenteric 
artery. 

Veins  of  the  Cecum  and  Colon. — These  are  the  superior  and 
inferior  mesenteric,  emptying  into  the  portal  system. 

Lymphatics  of  the  Cecum  and  Colon. — Those  of  the  sigmoid 
colon  empty  into  the  lumbar  glands;  those  of  the  rest  of  the  colon 
into  the  mesenteric  glands. 

Nerves  of  the  Cecum  and  Colon. — The  cecum,  ascending  colon, 
and  right  half  of  the  transverse  colon  are  supplied  by  the  superior 
mesenteric  plexus,  a  branch  of  the  celiac  plexus.  The  rest  of  the 
colon,  including  the  sigmoid  flexure,  is  supplied  by  the  inferior 
mesenteric  plexus,  a  branch  of  the  aortic  plexus. 

Arterial  Supply  of  the  Rectum. — They  are  the  superior  hemor- 
rhoidal (of  the  inferior  mesenteric) ;  the  middle  hemorrhoidal  (of  the 
internal  iliac) ;  the  inferior  hemorrhoidal  (of  the  internal  pudic) ; 
branches  from  the  sacromedia  (of  the  abdominal  aorta) ;  branches 
from  the  sciatic  (of  the  internal  iliac) ;  in  the  female,  branches  from 
the  vaginal. 

Veins  of  the  Rectum. — They  are  chiefly  from  the  superior 
hemorrhoidal,  passing  to  the  inferior  mesenteric  and  to  the  portal 
system;  part  of  the  other  hemorrhoidal  veins  empty  into  the  internal 
iliac  veins,  and  so  enter  the  general  venous  system. 

Anastomosis  thus  occurs  in  the  rectum  between  the  portal  and 
the  general  venous  system,  and  there  is  a  communication  also  with 
the  other  abdominal  veins. 

Lymphatics  of  the  Rectum. — They  empty  into  the  sacral  and 
lumbar  glands  from  the  rectum;  from  the  anus  into  the  inguinal 
glands. 


ANATOMY    OF   THE    STOMACH    AND    INTESTINES  33 

Nerves  of  the  Rectiim. — The  cerebrospinal  nerves  come  from 
the  sacral  plexus ;  the  sympathetic  nerves  from  the  inferior  mesenteric 
and  superior  hypogastric  plexus. 

HISTOLOGY  OF  THE  LARGE  INTESTINE 

The  large  intestine  (colon),  like  the  small  intestine,  consists  of 
four  coats:     serous,  muscular,  submucous,  and  mucous. 

The  longitudinal  muscular  fibers  of  the  large  intestine,  however, 
are  arranged  in  three  bands  (teniae)  running  along  the  wall,  as  already 
described. 

The  serosa  and  submucosa  resemble  those  of  the  small  intestine 
in  structure. 

The  mucosa  of  the  large  intestine  differs  from  that  of  the  small 
intestine  in  that  the  villi  and  circular  folds  of  Kerkring  (valvulae 
conniventes)  are  absent.  The  glands  of  Lieberkiihn  are  somewhat 
longer  and  at  times  curved. 

The  mucous  membrane  of  the  rectum  is  thicker,  redder,  and  more 
generously  supplied  with  blood-vessels  than  that  of  the  colon. 

When  the  rectum  is  empty  the  mucous  membrane  of  the  upper 
part  is  thrown  into  a  multitude  of  superficial  transverse  velvety 
folds.  From  two  to  seven  folds  (Houston's  valves)  are  made  more 
prominent  by  distention  (Gant). 

Just  above  the  anus  are  a  number  of  longitudinal  folds  (columns 
of  Morgagni),  extending  for  |  to  -f  inch  (8.46-15.23  mm.). 

The    mucous    membrane    of   the    rectum    consists   of    columnar 
epithelium,  except  at  the  lowest  portion,  a  narrow  la)-er  of  stratified 
pavement-like    epithelium,    transitional    between    skin    and    rectal 
mucosa.     The  upper  part  of  the  rectum  resembles  the  colon. 
3 


CHAPTER   II 
PHYSIOLOGY  OF  DIGESTION 

■  The  stomach  and  intestines  form  an  important  part  of  the  diges- 
tive tract,  and  in  order  to  understand  their  functions  it  will  be  neces- 
sary to  review  briefly  the  process  of  digestion.  This  term  includes 
those  processes  which  convert  the  food  into  such  condition  that  it 
becomes  fit  to  enter  the  circulation  and  afford  nutrition  to  the  human 
organism.  These  changes  are  brought  about  by  means  of  certain 
ferments  contained  in  the  saliva,  gastric  juice,  bile,  pancreatic  juice 
and  intestinal  juice,  which  are  a  part  of  the  human  organism  at  birth. 

There  are  certain  fermentative  and  putrefactive  processes  which 
take  place  in  the  gastro-intestinal  canal,  the  result  of  bacterial 
invasion,  which  play  an  important  part  in  the  physiolog}^  and 
pathology  of  this  tract. 

The  first  ferment  (ptyalin)  with  which  the  food  comes  in  contact 
by  the  act  of  chewing,  is  found  in  the  saliva.  The  latter  is  alkaline 
in  reaction,  of  low  specific  gravity  (1.002  to  1.0009),  and  contains 
water,  ptyalin,  mucus,  epithelia,  albumin,  and  salts. 

The  ptyalin,  which  converts  starch  into  maltose,  or  sugar,  begins 
its  action  on  the  food  already  in  the  mouth,  but  the  principal  uork 
is  done  during  the  first  period  of  digestion  within  the  stomach. 
Under  normal  conditions  during  this  early  stage  of  gastric  digestion 
the  free  hydrochloric  acid  is  becoming  combined  acid,  and  the  action 
of  the  ptyalin  continues;  but  if  the  free  hydrochloric  acid  be  exces- 
sively secreted,  further  digestion  of  the  starch  is  interfered  with; 
this  physiologic  fact  has  a  bearing  on  the  treatment  of  hyperchlor- 
hydria.  We  must  remember  that  thorough  mastication  of  the  food, 
which  promotes  salivary  secretion,  and  the  care  of  the  teeth  have 
an  important  bearing  on  digestion.  It  has  been  demonstrated  that 
acid  fermentation  in  the  mouth  interferes  with  the  action  of  the 
saliva,  and  that  cleansing  the  mouths  of  nursing  infants  will  diminish 
fermentative  processes  in  the  gastro-intestinal  tract. 

Hemmeter  has  apparently  recently  demonstrated  on  dogs  that 
the  salivary  glands  secrete  a  chemical  substance  during  mastication 
which  passes  into  the  blood  and  starts  up  the  secretion  of  the  gas- 
tric juice.  After  extirpation  of  the  glands,  HCl  and  rennin  were 
much  reduced.  Intravenous  injection  of  salivary  gland  extracts 
partially  restored  gastric  secretion. 

34 


PHYSIOLOGY    OF    DIGESTION  35 

THE  GASTRIC  JUICE 

Hydrochloric  acid  was  discovered  in  the  gastric  juice  by  Prout 
in  1824;  and  Beaumont,  in  1833,  by  his  experiments  on  St.  Martin 
with  his  gastric  fistula,  greatly  advanced  our  knowledge.  Schwam, 
in  1836,  discovered  the  pepsin  ferment;  and  Bedder  and  Schmidt, 
in  1854,  showed  that  the  acid  of  the  gastric  juice  is  hydrochloric  acid. 

The  gastric  juice  is  a  clear,  colorless  fluid,  of  an  acid  reaction 
and  a  specific  gravity  of  1.002  to  1.003.  It  contains  w-ater,  salts, 
inorganic  matter,  proteids,  h3'drochloric  acid,  pepsin,  rennet,  and 
recently  a  fat-splitting  ferment  has  been  discovered. 

The  quantity  of  this  secretion  in  twenty-four  hours  is  estimated 
to  be  about  3  pints.  The  degree  of  acidity  varies  from  o.  i  to  0.2 
per  cent.  Pepsin  and  rennet  when  first  secreted  are  inactive  bodies, 
known  as  pepsinogen  and  rennet-zymogen,  but  on  coming  into 
contact  with  the  hydrochloric  acid  become  converted  into  active 
pepsin  and  rennet.  Various  theories  have  been  advanced  to  explain 
the  production  of  the  gastric  juice,  hew  an  inorganic  acid  comes  to  be 
secreted  by  the  blood  which  is  of  alkaline  reaction.  We  are  so  far 
forced  to  accept  the  view  that  the  secretion  of  the  gastric  juice  must 
be  due  to  the  specific  action  of  the  cells. 

Through  the  combined  action  of  hydrochloric  acid  and  pepsin, 
it  converts  the  albuminates  into  propeptones  and  peptones,  which 
are  more  soluble.  The  rennet  ferment  curdles  the  milk.  A  small 
percentage  of  fat  is  split  into  fatty  acids. 

It  has  the  property  of  converting  cane-sugar  into  grape-sugar, 
and  gelatin  into  a  soluble  peptone  which  does  not  coagulate. 

Some  of  the  substances  contained  in  the  Hquefied  chyme  are 
absorbed  through  the  stomach-walls,  such  as  peptone,  sugar,  salts, 
and  possibly  propeptone.  Meltzer  has  demonstrated  that  only  a 
small  quantity  of  water  is  absorbed  in  the  stomach.  The  residue 
of  the  gastric  contents  passes  into  the  small  intestine,  where  further 
digestive  processes  occur  through  the  action  of  the  other  ferments 
and  the  principal  absorption  takes  place. 

The  motor  function  of  the  stom.ach  is  of  importance  in  the  process 
of  digestion,  as  by  its  active  and  passive  movements  physical  changes 
are  brought  about  in  the  ingesta.  The  food  is  brought  more  closely 
in  contact  with  the  stomach-walls  and  becomes  more  Hquefied.  The 
pylorus  opens  and  closes  at  intervals,  and  allows  the  entrance  of  the 
chyme  into  the  small  intestine,  the  exact  intervals  of  which  we  do 
not  know.  About  two  to  three  hours  after  a  small  meal  and  six 
to  seven  hours  after  a  large  meal  the  stomach  is  empty. 

Cannon^  has  studied  the  movements  of  the  stomach  by  the 
rc-rays,  by  administering  food  mixed  with  bismuth,  and  by  observa- 
tion with  a  fluoroscope.  He  found  that  the  contractions  start  in  the 
middle  of  the  stomach  and  pass  toward  the  pylorus  at  regular 
intervals.  The  pyloric  end  of  the  stomach  lengthens  out  and  the 
1  American  Journal  of  Physiology,  1898. 


36  DISEASES    OF   THE    STOMACH    AND    INTESTINES 

peristaltic  waves  increase  during  advanced  digestion.  At  intervals 
the  pylorus  relaxes  and  the  contraction  squeezes  part  of  the  chyme 
into  the  duodenum. 

Cannon^  finds  that  carbohydrates  pass  out  soon  after  ingestion  and 
require  only  about  one-half  the  time  that  proteids  do  for  gastric 
digestion.  Fat  when  taken  alone  remains  for  a  considerable  time 
in  the  stomach,  and  if  combined  with  other  food  its  exit  is  dela)^ed. 
It  is  believed  that  chemic  stimuH,  such  as  hydrochloric  acid,  control 
the  opening  and  closing  of  the  pylorus. 

If  atony  of  the  stomach  be  present,  motor  insufficiency  and  stasis 
result,  and  the  latter  favors  fermentation  and  putrefaction.  It  has 
been  demonstrated  that  the  presence  of  hydrochloric  acid  in  con- 
siderable quantities  does  not  prevent  these  conditions  if  stasis  be 
present. 

INTESTINAL  DIGESTION 

Under  normal  conditions,  when  the  chyme  enters  the  duodenum 
its  reaction  is  acid.  It  is  here  subjected  to  the  influence  of  the  bile, 
pancreatic  juice,  and  intestinal  secretions,  all  of  which,  in  their 
action,  have  a  more  or  less  close  interdependence  upon  each  other. 

Bile. — The  bile  in  the  intestine  precipitates  the  pepsin  from  the 
chyme.  This,  however,  is  soon  dissolved.  Others  hold  that  albu- 
minoids are  precipitated  from  the  chyme,  together  with  the  pepsin, 
and  are  then  more  readily  absorbed.  It  does  not  have  a  deleterious 
effect  on  the  pancreatic  digestion. 

The  bile  is  one  of  the  chief  factors  in  gradually  altering  the  reaction 
of  the  chyme  to  neutral  or  alkaline,  and  it  strongly  supplements  the 
action  of  the  pancreatic  juice  in  emulsifying  fats,  and  its  absence  or 
diminution  lessens  this  function. 

Pawlow  believes  that  it  may  augment  slightly  the  effects  of  the 
other  pancreatic  ferments. 

One  of  its  chief  functions  is  undoubtedly  excretory,  and  through 
it  many  of  the  useless  products  of  metabolism  are  eliminated.  When 
absorbed  into  the  system  it  acts  as  a  poison  and  produces  a  definite 
toxemia. 

The  bile  is  a  clear,  tenacious  mucoid  fluid  with  an  alkaline  reaction, 
consisting  of  water,  bile-acid  salts  (glycocholic  and  taurocholic  acid), 
pigments  (bilirubin  and  biliverdin),  mucin,  cholesterin,  lecithin,  soaps, 
fats,  etc. ;  about  500  to  600  cc.  are  excreted  in  twenty-four  hours. 

Wm.  H.  Porter^  believes  that  the  precipitation  of  the  pepsin 
from  the  chyme  through  the  action  of  the  bile  is  necessary  for  the  action 
of  the  pancreatic  ferments,  and  the  enterokinase  of  the  intestinal 
juice,  as  the  pepsin,  as  long  as  it  remains  active,  inhibits  their  action. 

Some  consider  that  it  has  antifermentative  and  antiputrefactive 
powers,  and  that  it  helps  to  maintain  the  nutrition  of  the  epithelial 

1  American  Journal  of  Physiology,  1904. 

-  Indicanuria  a  Danger  Signal,  Postgraduate,  1907. 


PHYSIOLOGY    OF    DIGESTION  37 

cells.  Lindenberger  has  shown  experimentally  that  a  small  amount 
of  bile  combined  with  .05  per  cent,  of  lactic  acid  prevents  putrefac- 
tion in  an  infusion  of  pancreas,  while  lactic  acid  alone  has  no  effect. 

Von  Noorden  holds  that  bile  has  no  antiseptic  action. 

Clinically,  we  at  times  see  cases  of  indicanuria  with  the  presence  of 
bile  in  the  urine,  with  light-colored  stools  in  \vhich  there  is  no 
permanent  disappearance  of  indican,  though  there  is  a  temporary 
improvement  after  the  use  of  calomel,  etc.,  until  the  biliary  excretion 
into  the  intestine  is  restored  to  normal.  The  internal  use  of  the 
bile-salts,  which  can  be  given  as  inspissated  bile,  seems  to  be  of  some 
value.     Bile   possesses   slightly    purgative   qualities. 

The  liver  has  special  functions.  Many  of  the  substances  taken 
up  by  the  digestive  process  are  stored  there  until  used  in  the  system, 
namely,  some  of  the  peptones  and  sugar  in  the  form  of  glycogen. 
It  excludes  some  poisonous  matters  from  the  circulation.  Thus  it 
is  the  chief  organ  for  the  removal  of  indol  and  poison,  such  as  curare 
or  of  various  autotoxins.     Urea  is  also  formed  in  the  liver. 

Pancreatic  Juice. — The  pancreatic  juice  is  the  principal  factor 
of  digestion  in  the  intestinal  canal.  It  is  clear,  colorless,  alkaline, 
sticky  and  odorless,  quite  albuminous,  containing  water,  solids, 
proteids,  and  inorganic  matter. 

The  most  important  constituents  are  the  three  ferments: 

Amylopsin,  an  amvlolytic  enzvme,  which  converts  starch  into- 
maltose,  and  still  further  into  glucose.  Cane-sugar  is  converted 
into  grape-sugar,  while  milk-sugar  is  unchanged.  Some  of  the 
cellulose  ferments  form  marsh-gas  and  various  acids.  The  activity 
of  pancreatic  diastase  is  increased  by  very  small  quantities  of  acids 
(Chittenden). 

Steapsin,  a  lipolytic  ferment.  This  acts  upon  fats  by  splitting 
them  into  fatty  acids  and  glycerin;  and  this  action  is  increased  by 
the  bile.  The  fatty  acids  combine  with  the  alkalis  in  the  intestine 
to  form  soaps,  which  aid  in  the  emulsifying  of  fats,  and  thus  promote 
their  absorption.  The  emulsification  occurs  in  an  alkaline  medium, 
or  in  contact  with  the  alkaline  secretion  of  the  mucous  membrane. 

Trypsin,  a  proteolvtic  ferment,  changes  the  proteids  into  albu- 
moses  and  peptones.     There  is  probably  a  rennet-zymogen  also. 

The  fermicnt  acts  in  a  neutral  or  alkaline  medium,  though  slight 
degrees  of  acidity  seem  to  favor  it.  Indol  is  a  product  of  intestinal 
putrefaction,  and  not  from  the  action  of  the  pancreatic  ferment, 
as  was  formerly  supposed.     The  same  is  true  of  hypoxanthin. 

The  secretion  of  the  pancreatic  juice  is  not  reflex,  but  is  due  to 
direct  excitation  of  the  cells  of  the  pancreas  by  secretin  (Starling). 
This  is  formed  in  the  mucous  membrane  of  the  duodenum  and  jejunum 
and  reaches  the  pancreas  bv  the  blood-stream.  The  passage  of  the 
chyme  over  these  portions  of  the  small  intestine  stimulates  the 
production  of  secretin  or,  rather,  splits  it  off  from  "  presecretin," 
which  is  present  in  the  mucous  membrane. 


38  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

The  intestinal  juice  (succus  entericus)  consists  of  water, 
albumin,  mucin,  and  salts.  Ptyalin  and  an  inverting  enzyme  have 
been  discovered  therein.  It  seems  to  neutralize  the  acids  formed 
by  the  fermentation  of  the  carbohydrates  and  the  presence  of  mucin 
shows  it  to  be  of  service  in  aiding  peristalsis. 

Pawlow's  experiments  demonstrate  that  it  augments  the  activity 
Qi  the  pancreatic  ferments,  especially  of  trypsin.  The  fat-splitting 
and  amylolytic  pancreatic  ferments  are  augmented  by  the  succus 
entericus  from  all  parts  of  the  small  intestine,  while  that  from  the 
duodenum  augments  chiefly  the  proteolytic  ferment. 

Pawlow  found  enterokinase,  a  ferment  of  other  ferments,  which  is 
believed  to  be  necessary  to  excite  intestinal  ferments  into  activity. 

Erepsin,  another  ferment,  is  also  present,  which  transforms 
hemi-albuminose  into  other  bodies. 

Organized  Ferments. — There  exist  in  the  intestine  fermentative 
and  putrefactive  changes  produced  by  micro-organisms.^  At  birth 
the  gastro-intestinal  tract  is  sterile,  but  rapidly,  by  the  ingestion  of 
food  and  through  the  air  and  by  the  anus,  bacteria  of  various  types 
enter  this  tract. 

Herter^  has  estimated  their  number  at  one  hundred  and  twenty- 
six  billions  for  the  daily  human  excreta.  Many  of  them  are  no  longer 
living.  He  considers  the  chief  function  of  the  obHgate  bacteria 
(Bacillus  lactis  aerogenes,  Bacillus  coH,  and  Bacillus  bifidus)  to  be 
their  capacity  for  checking  the  development  of  other  types  of  organ- 
isms capable  of  doing  injury,  though  they  themselves  under  certain 
conditions  may  produce  much  harm.  Many  other  varieties  are 
described.  Some  observers  believe  that  there  is  a  so-called  normal 
fermentative  process  which  aids  -in  the  digestion  of  cellulose,  though 
Bergman  claims  there  are  enzymes  (intracellular)  which  decompose 
it. 

The  fermentative  processes  in  the  small  intestine  caused  by  the 
action  of  bacteria  on  the  carbohydrates  (Bacillus  lactis  aerogenes) 
leads  to  the  formation  of  ethyl  alcohol  and  various  organic  acids, 
such  as  lactic,  acetic,  paralactic,  succinic,  biliary  acids  and  albumin, 
peptone,  mucin,  sugar,  etc.  These  organic  acids  are  believed  to 
prevent  putrefaction  within  the  intestine,  to  partly  check  the  decom- 
position of  the  carbohydrates,  and  to  aid  in  producing  intestinal 
peristalsis,  which  render  putrefaction  less  likely.  The  lactic  acid 
in  koumyss,  matzoon,  bacillac  and  lactone  milk,  and  even  in  plain 
milk  (to  a  slighter  degree),  is  believed  to  lessen  putrefaction.  In 
the  lower  jejunum  and  ileum  the  reaction  is  acid. 

When  the  intestinal  contents  pass  into  the  colon  the  reaction 
becomes  alkaHne,  fermentation  stops,  putrefaction  begins,  and  the 

1  Proceedings  American  Medico-Psych.  Association,  April  21,  1905.  Some 
Observations  on  the  Relations  of  the  Gastro-intestinal  Tract  to  Nervous  and 
Mental  Diseases  (Kemp). 

2  Bacterial  Infections  of  the  Digestive  Tract. 


PHYSIOI.OGY   OF    DIGESTION  39 

fecal  odor  appears.  The  colon  bacilli  are  marked  factors  in  this 
process.  The  decomposition  of  the  albuminates  caused  by  bacteria 
goes  much  further  than  that  produced  by  pancreatic  digestion. 
Albumoses,  peptones,  lysin,  ammonia,  amido-acids,  etc.,  are  produced 
in  both  cases,  but  with  putrefaction  the  process  goes  further  and  we 
have  new  products  formed,  such  as  indol,  skatol,  paracresol,  phenol, 
various  acids  and  gases,  such  as  sulphuretted  hydrogen,  marsh-gas, 
carbon  dioxid,  etc. 

Some  of  these  products  of  decomposition  are  eliminated  unchanged 
in  the  urine,  such  as  the  oxyacids,  others,  like  the  phenols,  after 
further  oxidation,  and  others,  like  indol  and  skatol,  after  combination 
with  ethereal  sulphuric  acids.  For  example,  indol  forms  an  indoxyl- 
potassium  sulphate  or  indican,  and  is  so  eliminated  in  the  urine;  and 
thus  may  be  an  indication  of  the  amount  of  putrefaction  occurring 
in  the  intestine. 

The  causes  of  indicanuria  are  various,  such  as  excessive  proteid 
diet,  catarrh  of  the  small  intestine  causing  alterations  in  the  mucosa 
and  increased  intestinal  putrefaction  therefrom,  typhoid,  cholera, 
a  pus-cavity,  constipation,  alimentary  putrefaction,  decrease  of 
normal  digestive  fluids,  intestinal  obstruction,  and  peritonitis. 
Certain  drugs,  such  as  salol,  salophen,  and  creosote,  will  give  nearly 
similar  reaction,  while  urotropin  will  cause  its  disappearance.  These 
possible  conditions  must  all  be  considered. 

As  the  intestinal  contents  pass  through  the  large  intestine  they 
become  thickened  through  the  absorption  of  fluids  and  are  at  last 
eliminated  as  feces.  These  comprise  the  remains  of  undigested 
material,  excretory  material  from  the  intestines,  and  man}-  micro- 
organisms. 

The  quantit}^  of  feces  depends  upon  the  character  of  the  food, 
being  greater  after  a  vegetable  diet.  The  average  amount  after  a 
mixed  diet  is  about  100  to  150  gm. 

The  reaction  of  the  feces  is  ordinarily  alkaline,  though  occasionally 
variable.  The  odor  is  chiefly  due  to  skatol,  and  the  color  is  a  light 
or  dark  brown. 

Absorption  from  the  Intestines. — Absorption  chiefly  occurs 
in  the  small  intestine. 

The  proteids  are  usually  changed  into  albumoses  and  peptones 
before  absorption  occurs.  Albumin  may  be  absorbed  as  such, 
though  not  as  quickly. 

Absorption  of  the  albumoses  and  peptones  takes  place  by  the 
capillaries  and  not  by  the  lacteals.  They  are  reconverted  into 
albumin  before  reaching  the  blood-current,  probably  either  b}^  the 
epithelial  cells  or  leukocytes.  It  has  been  shown  experimentally 
that  they  do  not  reach  the  blood  as  peptones. 

Albuminates  from  animal  food  are  more  completely  absorbed 
than  those  from  vegetable  food,  on  account  of  the  indigestibility  of 
the  cellulose  and  the  increased  peristalsis  caused  by  the  latter. 


40  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

Absorption  of  the  Carbohydrates.- — These  are  chiefly  absorbed 
as  monosaccharids  through  the  capillaries  of  the  villi,  enter  the  liver 
through  the  portal  vein,  and  are  retained  as  glycogen  for  use  in  the 
animal  economy. 

If  sugar  is  absorbed  in  excess,  it  may  enter  the  general  circulation 
and  be  excreted  by  the  kidneys,  so-called  alimentary  glycosuria. 
It  may  also  cause  diarrhea. 

Carbohydrates,  as  starch,  are  absorbed  without  difficulty. 

Glucose,  levulose,  and  galactose  are  absorbed  as  such,  while 
cane-sugar  and  maltose  are  first  changed  to  these  products.  Milk- 
sugar  is  unchanged  and  absorbed  as  such,  or  undergoes  lactic-acid 
fermentation. 

Absorption  of  Fats. — The  greatest  amount  is  absorbed  as  an 
emulsion  (both  fats  and  fatty  acids),  though  some  absorption  takes 
place  in  the  form  of  soaps.  They  become  neutral  fats  after  absorp- 
tion. They  enter  the  lacteals  probably  through  the  action  of 
the  epithehal  cells  of  the  intestinal  wall  and  reach  the  thoracic 
duct. 

The  absorptive  power  for  fat  in  the  small  intestine  is  considerable, 
probably  over  300  gm.  per  day.  Olive  oil  and  butter  (fats  with  a 
low  melting-point)  are  absorbed  more  quickly  than  mutton  fat,  for 
instance  (fat  with  a  high  melting-point),  and  a  free  fat,  such  as  butter, 
is  taken  up  more  quickly  than  bacon,  which  contains  considerable 
connective  tissue. 

Water,  salts,  some  of  the  secretory  juices,  and  bile  are  readily 
absorbed. 

Disease  or  removal  of  the  pancreas  stops  the  absorption  of  fats, 
except  of  milk,  of  which  part  is  absorbed  in  emulsified  form. 

Absorption  in  the  Large  Intestine. — Water,  fluids,  and  salts 
are  well  absorbed,  in  fact,  markedly  absorbed,  as  is  noted  by  the 
change  in  the  character  of  the  intestinal  contents.  Albumin  and 
carbohydrates  are  absorbed  in  considerable  amount  and  fats  in  small 
quantities.  Advantage  is  taken  of  this  fact  for  the  employment  of 
nutritive  enemata. 

Intestinal  Peristalsis  (Motor  Function). — The  contents  are 
thoroughlv  mixed  by  the  movement  of  the  intestines,  and  the 
residuum  left  after  digestion  is  expelled  through  the  anus. 

There  are  three  types  described : 

The  intestine  contracts  at  a  certain  point  and  then  relaxes,  and 
continues  this  in  successive  segments  progressively  toward  the  anus, 
pushing  the  contents  forward   {ordinary  peristaltic  movements). 

Oscillating  movements,  by  which  the  coil  is  moved  to  and  fro 
along  the  mesentery,  with  no  particular  contraction.  The  contents 
are  mixed  up  by  these  movements  and  not  propelled  forward. 

Rotary  movements,  by  which  a  coil  contracts  in  a  circular  direction 
rapidly  along  the  intestine  for  15  or  20  cm.  in  a  violent  manner. 

The  last  is  usually  pathologic  and  occurs  when  there  is  con- 


PHYSIOLOGY    OF    DIGESTION  4 1 

siderable  gas,  after  indiscretions  in  diet,  or  in  stenosis.  It  is  observed 
only  in  the  small  intestine. 

Peristaltic  action  is  much  more  rapid  in  the  small  intestine. 
After  ingestion  of  a  small  meal  the  stomach  becomes  empty  in  about 
two  hours,  the  small  intestine  in  the  same  length  of  time ;  but  in  the 
large  intestine  it  takes  at  least  twenty  hours  before  the  contents  are 
expelled. 

Nothnagel  has  never  seen  a  physiologic  antiperistalsis  (reversed 
peristalsis)  beginning  from  the  anal  direction  upward  toward  the 
stomach,  though  some^  describe  an  intermittent  antiperistalsis 
occurring  in  the  ascending  colon.  It  is  said  that  strong  injections 
of  salt  water  into  the  colon  will  produce  this  effect. 

Nervous  Control  of  Peristalsis. — Auerbach's  and  Meissner's 
plexuses  are  probably  the  automatic  centers  for  peristalsis,  but  there 
are  central  agencies.  For  example,  fright  or  excitement  may  cause 
diarrhea. 

The  splanchnic  nerve  contains  inhibitory  fibers  for  the  control 
of  intestinal  peristalsis. 

Ehrmann  claims  that  the  longitudinal  muscles  are  stimulated 
by  the  splanchnics  and  inhibited  by  the  vagus,  and  the  circular 
muscles  stimulated  by  the  vagus  and  inhibited  by  the  splanchnics. 

The  ch3'me  acts  as  the  normal  stimulus  to  peristalsis  through 
the  nerves.  Toxic  material  that  has  been  ingested  or  developed  in 
the  intestinal  canal,  indigestible  food,  organic  acids  from  excessive 
fermentation,  and  too  hot  or  too  cold  drinks,  may  overstimulate 
the  peristaltic  action  and  be  the  cause  of  diarrhea. 

1  W.  B.  Cannon,  Amer.  Jour.  Physiol.,  vol.  vi.,  p.  253,  has  demonstrated  by 
the  Rontgen  rays  that  antiperistaltic  movements  occur  normally  in  the  cecum, 
ascending  and  transverse  colon,  thoroughly  churning  and  mixing  the  food,  and 
bringing  it  in  more  perfect  contact  with  the  absorbing  surface  of  the  colon. 


CHAPTER   III 

INTERROGATION  OF  THE  PATIENT  (HISTORY) 

In  every  case  suffering  from  symptoms  pointing  to  the  gastro- 
intestinal tract,  before  the  physical  examination  is  undertaken,  the 
patient  should  be  carefully  interrogated  as  to  his  general  history 
and  the  past  and  present  symptoms. 

I  shall  briefly  indicate  the  form  of  taking  and  preserving  the 
history  of  such  cases : 

Date Diagnosis No.  of  patient 


Name Nativity 

Age Occupation 

Sex 

Family  History 

Tuberculosis:  Rheumatism: 

Syphilis:  Malaria: 

Diphtheria:  Influenza: 

Scarlatina:  Nephritis: 

Typhoid :  Heart  disease : 

Gout:  '  Disease  of  liver: 

Habits 
Tea — cups:  Sexual  excess: 

Coffee — cups:  Mastication: 

Tobacco:  Character  of  food : 

Alcohol: 

Past  History  of  Present  Complaint 
Began : 
Duration : 

Onset — 

Sudden: 

Gradual : 
Probable  cause: 

Symptoms — 

Progressed : 

Same  in  character: 

Changed  in  character: 

Loss  of  flesh — 
Present: 
Increasing: 
Absent : 

Bowels — 

Constipation:  Mucus: 

Diarrhea:  Blood: 

Alternating:  Odor: 

Regular: 

42 


INTERROGATION    OF    THE    PATIENT    (HISTORY) 


43 


Present  Condition  and  History 


Headache — 

Character: 

Location: 

Time  of: 

Vertigo — 

Nervousness: 

Drowsiness: 

Sleeplessness: 

Appetite — 

Good: 

Bulimia  (canine  hunger) 

Anorexia  (loss): 

Polyphagia: 

Time: 

Akoria: 

Parorexia  (perversion) : 

Thirst: 

Taste — 

Normal: 

Sour: 

Bitter: 

Sticky: 

Time: 

Deglutition: 

Dysphagia — 

With  solids: 

With  liquids: 

Abnormal  sensations — 

Bloating: 

Pressure: 

Fulness: 

Weight: 

Time : 

Belching — 

Quantity: 

On  empty  stomach : 

Time  of: 

Odor: 

On  full  stomach: 

Regurgitation— 

Water-brash : 

Sour: 

Time : 

Rumination: 

Pyrosis  (heart-burn) — 

Time: 

Duration: 

Pains— 

Location : 

Circumscribed : 

Cardialgia: 

Diffuse: 

Gastralgia: 

Radiating: 

Character : 

Sudden : 

Time  of  appearance: 

Slow: 

Duration : 

Relieved  by  pressure: 

Affected  by  position: 

Increased  by  pressure; 

Affected  by  food  or  drink: 

Local  tenderness — 

Position: 

Nausea — 

Time: 

Affected  by  food : 

44 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


Vomiting — 
Time  : 
Frequency: 
Quantity : 
Character  of: 
Odor: 
Taste : 

Stools — 

Regular: 

Constipation: 

Diarrhea: 

Alternating  constipation 

and  diarrhea: 
Number  of  movements: 


Blood  and  its  character: 

Bile: 

Mucus: 

Easy: 

Difficult: 

Relief  of  pain  by: 


Time  of  appearance: 

Undigested  food: 

Mucus: 

Blood: 

General  character: 

Bile: 


General  health  and  strength — 
Loss  of  weight: 

Symptoms  Referable  to  Circulatory  System 

Symptoms  Referable  to  Nervous  System 

Chief  Complaint 

After  the  physical  examination  has  been  made,  the  results 
should  be  incorporated  with  the  history,  as  should  also  the  data 
secured  from  examination  of  the  gastric  contents  and  stool. 

General  Physical  Exam,ination  Comprises — 

Tongue:  Uvula:  Tonsils:  Pharynx: 

Teeth: 

Eyes — as  to  difficulty  in  reading  or  headache  therefrom;  exophthalmos. 

Nose — as  to  nasal  discharge. 

Ears — as  to  deafness. 

Heart: 

Lungs: 

Liver: 


Tenderness: 
Motor  function: 
Typanitis: 
Gastric  analysis: 
Tumor : 


Stomach — 
Position: 
Normal : 
Dilated: 
Gastroptosis: 

Spleen: 

Kidneys — 
Position : 
Urine : 

Intestines — 
Position : 
Tender  points: 
Thickening: 

Rectum — 

Local  examination: 

In  some  cases  microscopy  and  fermentation  test  of  stool. 
Nervous  system: 
Weight  of  patient: 
Examination  of  genital  organs — in  some  cases. 


Tympanitis: 
Borborygmi : 


CHAPTER    IV 

GENERAL  METHODS  OF  PHYSICAL  EXAMINATION 

As  patients  who  complain  of  digestive  disturbances  may  suffer 
from  disease  of  other  organs  which  may  be  the  cause  of  the  symptoms, 
a  thorough  physical  examination  should  be  made  in  everv  case. 

The  first  step  should  be  an  examination  of  the  heart  and  lungs. 
The  character  and  rapidity  of  the  pulse  and  respiration  should  be 
noted  and  a  specimen  of  urine  requested  for  analysis. 

In  all  acutely  commencing  processes  pointing  to  the  digestive 
tract,   the  temperature  should  be  taken. 

GENERAL  INSPECTION 

The  general  appearance  of  the  patient  may  afford  valuable 
information.  With  cancer,  there  is  often  the  sallow  and  emaciated 
appearance  (cachexia)  with  anemia ;  with  gastric  neurosis,  the  patient 
may  often  appear  rosy  and  well  nourished;  while  with  ulcer  there 
is  frequently  marked  anemia  and  the  face  may  have  the  appearance 
of  suffering.  Protrusion  of  the  eyeballs,  with  inability  of  complete 
closure  of  the  lids,  taken  in  connection  with  tachycardia,  are  suggest- 
ive of  Graves'  disease,  even  though  no  thyroid  enlargement  be 
present.  The  skin  should  be  inspected  for  eruptions  and  the  exanthe- 
mata. 

Oral  Cavity. — This  should  be  carefully  inspected.  Defective 
and  carious  teeth  or  inflammation  or  abscess  of  the  gums  may  give 
rise  to  gastric  disorders.  Disease  of  the  posterior  nares  or  middle 
ear,  with  resulting  discharges  passing  into  the  pharynx,  may  be 
factors. 

The  tongue  was  formerly  regarded  as  a  mirror  of  the  stomach, 
but  it  can, hardly  be  so  considered,  as  there  are  some  gastric  affections 
in  which  the  appearance  of  the  tongue  is  normal;  while  in  smokers, 
for  example,  the  tongue  may  be  coated  and  yet  no  gastro-intestinal 
disturbance  be  present.  A  thick  gray  or  grayish-yellow,  moist,  coated 
tongue  showing  indentations  is  suggestive  of  chronic  gastritis;  while 
with  ulcer  it  may  be  dry  and  red  with  a  white  median  stripe,  or 
sm.ooth  and  moist,  or  slightly  furred. 

The  condition  of  the  mouth,  smoking,  drinking,  and  the  teeth,  have 
a  decided  bearing  on  its  appearance.  This  is  true  in  reference  to 
the  odor  of  the  breath.  I  hardly  deem  the  tongue  diagnostic  in 
diseases  of  the  gastro-intestinal  tract  except  in  association  with 
other  symptoms. 

45 


46  DISEASES    OF   THE    STOMACH    AND    INTESTINES 

AVith  the  typhoid  state,  we  have  the  narrow  tongue,  with  the 
deep  median  fissure,  thickly  furred,  the  tip  and  edges  being  red  and 
denuded,  or  the  dry  brown,  fissured,  and  tremulous  tongue;  while 
with  scarlet  fever  and  in  some  other  acute  specific  infections  there 
is  the  so-called  strawberry  or  raspberry  tongue,  with  bright  red 
projecting  papillae. 

The  uvula  is  sometimes  elongated,  and  may  cause  reflex  digestive 
disturbances.  In  the  pharynx  and  tonsils  there  may  be  inflammatory 
conditions  of  an  acute  or  chronic  type  which  influence  the  case. 

Inspection  of  the  neck  is  important.  Enlarged  thvroid  with 
tachycardia  is  diagnostic  of  Graves'  disease,  and  a  swelhng  to  the 
left  of  the  larynx,  which  increases  in  size  after  the  ingestion  of  food, 
is  suggestive  of  a  diverticulum  of  the  esophagus. 

Examination  of  the  Esophagus. — The  cardinal  svmptom  of 
esophageal  disease  is  dysphagia,  with  or  without  regurgitation. 
The  object  of  examination  is  to  determine  whether  a  stricture  or  a 
diverticulum  is  present. 

Palpation  of  the  esophagus  is  possible  in  the  neck,  usually  on 
the  left  side  behind  the  trachea.  A  tumor  found  here  mav  be  a 
diverticulum  distended  with  food  or  fluid.  It  is  sometimes  possible 
to  empty  it  by  the  exertion  of  pressure. 

A  brawny  swelling,  in  some  cases  with  subcutaneous  emphvsema, 
may  result  from  perforation  or  rupture  of  the  esophagus,  with 
inflammation,  which  proceeds  to  suppuration.  An  abscess  in  this 
locality  may  be  due  to  caries  of  the  vertebrae. 

Auscultation  of  the  esophagus  is  often  of  ser^'ice.  Place  the 
stethoscope  posteriorly,  to  the  left  of  the  spine,  at  the  level  of  the 
sixth  dorsal  vertebra,  and  at  a  signal  let  the  patient  swallow  a 
mouthful  of  water.  At  the  instant  of  swallowing .  the  deglutitorv 
sound  is  heard,  followed  in  six  or  seven  seconds  by  the  esophageal 
bruit,  which  resembles  the  sound  one  hears  when  swallowing  saliva. 
Three  to  five  seconds  later  there  is  a  second  sound  caused  by  the 
fluid  entering  the  stomach  or  by  regurgitation  of  air.  If  the  first 
sound  is  dela3'ed  longer  than  seven  seconds,  or  replaced  by  a  splashing 
or  gurgling  noise,  or  if  the  second  sound  is  delated  longer  than  five 
to  twelve  seconds,  partial  stenosis  may  be  suspected.  If  both  sounds 
are  absent,  there  is  probably  nearly  complete  or  complete  stenosis. 

Gurgling  sounds  lasting  several  minutes  and  heard  along  the  left 
side  of  the  spine  are  probably  due  to  contractions  in  a  diverticulum, 
or  in  the  dilated  portion  of  the  canal  above  a  stricture. 

Instrumental  examination  of  the  esophagus  is  made  by  flexible 
stomach-tubes  of  various  sizes,  the  safest  method,  or  by  flexible 
solid  bougies  or  sounds.  • 

The  esophagoscope  is  of  chief  value  in  locating  foreign  bodies 
and  aff"ording  direct  means  of  removal. 

In  the  use  of  the  sound  one  must  remember  that  it  is  6  inches 
from  the  incisors  to  the  commencement  of  the  esophagus  at  the 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION  47 

cricoid  cartilage;  9  inches  to  the  crossing  of  the  left  bronchus,  and 
16  inches  to  the  cardiac  orifice  of  the  stomach.  There  is  normally 
some  constriction  of  the  esophagus  at  these  three  points. 

Obstruction  to  the  passage  of  the  tube  may  be  due  to  esophageal 
spasm,  but  by  waiting  this  will  usually  subside.  I  have  found  that 
in  some  of  these  cases  a  large  tube  can  be  passed  more  readily  than 
a  small  one.  If  the  tube  pass  readily  on  one  occasion  and  refuses 
to  pass  on  another,  it  has  probably  slipped  into  a  diverticulum,  or 
the  latter  has  filled  up  and  by  pressure  prevented  the  passage  of 
the  instrument. 

If  the  obstruction  is  permanent,  one  must  decide  whether  it  is 
due  to  stricture  (narrowing)  or  external  pressure,  such  as  from 
aneurism,  tumor,  or  enlarged  glands.  Syphilis,  cancer,  and  con- 
traction following  burns  from  acids  or  alkalis  are  the  principal  causes 
of  stricture.     Congenital  stricture  is  rare. 

If  stricture  be  present,  the  locality,  caliber,  and  permeability 
must  be  determined. 

Locality. — Pass  the  tube  to  the  strictured  point,  nip  it  close  to 
the  incisor  teeth,  and  measure  the  distance  from  here  to  the  entering 
tip  of  the  tube  after  withdrawal. 

Caliber. — Sounds  of  varying  diameters  will  determine  the  caliber 
by  finding  one  which  will  pass  the  obstruction.  By  the  esophageal 
bruit  and  the  use  of  a  somewhat  rigid  sound  one  can  tell  whether  or 
not  the  obstruction  is  permeable. 

Occasionally  small  portions  of  new  growth  may  be  found  in  the 
openings  of  a  fenestrated  tube.     Blood  shows  ulceration  or  erosion. 

Contra- indications. — The  tube  should  never  be  passed  if  there 
is  aneurism  of  the  thoracic  aorta  or  recent  vomiting  of  blood. 

Examination  of  the  Abdomen. — The  special  methods  of  physical 
examination  of  the  stomach  and  intestines  are  described  in  the  parts 
of  this  volume  devoted  to  these  subjects.  It  seems  advisable  to 
refer  to  the  general  methods  of  examination  of  the  abdomen  and 
the  other  viscera. 

Anatomic  Landmarks. — The  ensiform  appendix  and  down-curved 
arches  of  the  ribs  constitute  the  upper  bony  landmarks.  The  iliac 
crests,  anterior  superior  spines  of  the  iha,  and  the  symphysis  pubis 
in  the  median  line  are  the  lateral  and  lower  boundaries. 

The  linea  alba  lies  between  the  recti  muscles  in  the  median  line, 
runs  from  the  ensiform  appendix  to  the  pubic  symphysis,  and  is 
visible  as  a  groove  above  the  umbilicus. 

The  umbiHcus  is  somewhat  variable  in  its  position,  though  usually 
lying  about  2  inches  above  the  bispinal  line  drawn  transversely 
between  the  anterior  superior  spines  of  the  ilia.  The  recti  muscles 
lie  on  each  side  of  the  linea  alba  and  are  bounded  externally  by  the 
lineae  semilunares,  which  run  with  an  outward  curve  from  the  lowest 
part  of  the  seventh  rib  to  the  pubic  spines.  These  lines  lie  on  each 
side  about  3  inches  from  the  umbilicus. 


48 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


Topographic  Areas. — In  order  to  describe  the  situation  of  organs 
or  lesions,  the  surface  of  the  abdomen  is  divided  into  regions,  of  which 
the  method  depicted  in  Fig.  15  is  in  general  use. 

There  are  nine  regions  divided  off  by  four  lines,  two  horizontal 
and  two  vertical.  The  horizontal  lines  are  the  infracostal  or  sub- 
costal, drawn  transversely  at  the  level  of  the  inferior  borders  of  the 
tenth  ribs,  and  the  bispinal  line,  connecting  the  anterior  superior 
spines  of  the  ilia.  The  vertical  lines  pass  through  the  center  of 
Poupart's  ligament  on  each  side  and  are  downward  prolongations  of 
the  mammillary  lines  of  the  thorax.  The  boundary  lines  between 
the  epigastric  and  hvpochondriac  regions  correspond  with  the  costal 
margins,  and  the  iliac  regions  correspond  to  the  so-called  inguinal 
regions. 


Fig.  15. — Topographic  areas  of  the  abdomen. 


A  second  method  of  dividing  the  abdomen  is  by  a  vertical  and 
transverse  line  through  the  umbilicus,  forming  four  quadrants.     - 

In  reference  to  the  various  landmarks,  one  often  measures  dis- 
tances by  the  finger-breadth.  The  average  finger-breadth  is  f  inch; 
two,  i\  inches;  etc. 

A  hand-breadth  averages  3^  to  4  inches. 

Preparation  of  the  Patient  and  Technic. — The  patient  should 
preferably  lie  in  bed  in  the  dorsal  position,  quite  flat,  with  the  head 
on  a  single  thin  pillow.  The  same  posture  should  be  assumed  if  the 
examination  be  made  on  the  office  table.  The  bedclothing  should 
be  drawn  well  down,  except  the  sheet,  under  cover  of  which  the 
nightdress  or  undershirt  should  be  drawn  up  to  the  lower  sternum, 
and  the  sheet  then  folded  down  to  a  short  distance  above  the  pubes. 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION  49 

The  sheet  may  not  be  required  in  the  office,  though  generally  prefer- 
able. 

The  patient  should  lie  as  symmetrically  as  possible,  with  the  pubic 
spines  at  the  same  level  and  a  good  light  secured.  It  is  of  value  to 
make  an  observation  also  in  the  sitting  or  standing  position,  as  pro- 
lapse of  the  abdominal  ivalls  or  viscera  can  thus  be  more  clearly  seen. 

Inspection. — Inspection  should  be  from  the  front,  sides,  and  back. 
It  is  of  great  importance.  With  excessive  abdominal  distention  the 
skin  is  smooth,  shining,  and  stretched.  Copper-colored,  scaly, 
somewhat  circular  spots  are  significant  of  secondary  syphiHs;  and 
whitish  streaks,  or  striae,  of  long-continued  distention,  such  as  from 
pregnancy  or  ascites. 

Typhoid  eruption  or  exanthemata  may  in  some  cases  be  in 
evidence.  Glandular  enlargements  in  the  groin  or  old  scars  are 
suggestive  of  venereal  infection.  Inguinal  or  femoral  hernia  may 
be  observed. 

Inspection  of  the  blood-vessels  often  affords  valuable  information. 
Enlarged  veins  radiating  from  the  umbilicus  (the  caput  medusae) 
are  significant  of  portal  obstruction,  cirrhosis,  or  tumor  of  the  liver. 
General  enlargement  of  the  abdominal  veins  may  be  present  in 
similar  conditions,  or  from  pressure  on  the  venae  cavae  by  thoracic 
or  abdominal  tumors.  If  a  dilated  lateral  vein  is  present  running 
up  the  right  midaxillar}^  line,  it  should  be  emptied  by  massage,  and 
the  method  of  its  repUing  carefully  observed.  If  the  portal  vein,  or 
the  inferior  vena  cava,  is  obstructed,  the  direction  is  upward;  but 
if  the  superior  vena  cava  is  pressed  upon,  the  direction  is  downward. 

Distention  of  the  veins  in  the  pubic  region  alone  shows  some 
probable  obstruction  below  the  liver. 

Enlarged  epigastric  arteries  are  diagnostic  of  obstruction  of  the 
aorta  or  iUacs. 

An  umbilicus  that  protrudes  is  suggestive  of  hernia,  ascites, 
pregnancy,  or  some  form  of  abdominal  distention. 

Absence  of  respiratory  abdominal  movements,  with  accentuation 
of  thoracic  respiration,  is  significant  of  peritonitis. 

Peristaltic  unrest  (visible  peristalsis)  is  usually  diagnostic  of 
stenosis  of  the  pylorus  or  intestines  or  of  intestinal  obstruction. 
It  may  rarely  occur  normally  in  thin  persons. 

One  can  at  times  infer  the  site  of  the  obstruction  by  the  location 
and  character  of  the  peristalsis.  The  waves  run  in  the  stomach 
from  left  to  right  and  in  the  transverse  colon  from  right  to  left.  If 
the  obstruction  is  near  the  ileocecal  valve,  the  swollen  and  moving 
coils  of  the  intestine  lie  one  above  the  other  in  the  central  part  of 
the  abdomen  (ladder  pattern). 

If  the  constriction  is  lower  down  in  the  large  intestine,  the  dis- 
tention is  chiefly  visible  in  the  course  of  the  colon  (in  the  circumfer- 
ence of  the  abdomen).  A  recurring  protuberance  at  one  point, 
disappearing  with  a  loud  sound,  is  probably  near  the  point  of  stenosis. 
4 


50 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


Protrusion  from  tumor  can  at  times  be  observed. 
Method   of    Abdominal   Palpation. — The    right    hand    should    be 
warmed  and  laid  flat  upon  the  surface  of  the  abdomen,  the  physician 
sitting  to  the  right  of  the  patient  (Fig.  i6). 

Palpation  should  be  at  first  by  somewhat  circular  pressing 
movements,  sliding  the  skin  over  the  parts  beneath,  and  passing  from 
one  portion  of  the  abdomen  to  another.  One  should  not  poke 
suddenly  with  the  finger-tips.  Gradually  deeper  localized  palpation 
may  be  made  with  the  finger-pulps  to  determine  the  presence  of 

tender  spots,  or  the  shape, 
size,  and  mobility  of  existing 
masses  or  swellings. 

The  facial  appearance  of 
the  patient  rather  than  the 
verbal  expression  tells  whether 
true  pain  is  present.  Tender- 
ness suggests  inflammation  or 
ulceration.  McBurney's  point 
should  always  be  explored  for 
appendicitis. 

If  firm  pressure  elicits  ten- 
derness, it  is  apt  to  be  real 
and  deep  seated,  rather  than 
a  surface  lesion  or  hyperes- 
thesia. 

If  hysteria  is  suspected, 
the  patient's  attention  can  be 
diverted  by  pressing  on  a  dif- 
ferent part  of  the  surface  with 
one  hand,  while  the  other  hand 
explores  the  original  seat  of 
pain  complained  of.  Absence 
of  true  tenderness  is  thus  fre- 
quently revealed. 
If  the  abdominal  muscles  are  contracted,  the  knees  and  thighs 
should  be  flexed  and  a  pillow  placed  beneath  the  head  and  shoulders 
to  secure  relaxation.  The  flexion  of  the  lower  limbs  I  believe  prefera- 
ble in  every  case.  Deep  and  rapid  respirations  at  the  end  of  expiration 
relax  the  muscles  momentarily  and  render  examination  more  easy. 
This  method  aids  in  differentiation;  whether  the  mass  felt  is  due  to 
contraction  of  the  belly,  of  a  muscle,  such  as  of  the  rectus,  and 
whether  a  tumor  is  movable  with  respiration.  Howard  Kelly 
recommends  vibratory  movements  with  the  fingers  while  palpating. 
In  some  cases  reinforced  palpation,  the  left  hand  exerting  pressure 
over  the  right,  as  in  Fig.  17,  is  of  value,  especially  in  examination 
of  the  deeper  organs.  During  examination  forced  respiration  should 
be  taken,  and  at  each  expiration  the   abdominal    wall    should    be 


Fig.  16. — Abdominal  palpation. 


GENERAL   METHODS    OF    PHYSICAL   EXAMINATION 


51 


pressed  upon  firmly,  maintaining  during  inspiration  the  ground  which 
has  been  gained.  This  method  is  of  special  service  in  determining 
a  chronic  enlarged  appendix,  as  suggested  by  Edebohls  and 
R.  T.  Morris. 

If  there  is  fluid  in  the  peritoneal  cavity  and  one  desires  to 
palpate  an  organ  which  is  obscured  by  its  presence,  sudden  deep 
pressure  wdth  the  finger-tips  ("dipping")  wdll  displace  the  fluid. 
In  some  cases  a  general  anesthetic  may  be  necessary  for  a  thorough 
examination. 

All  the  regions  of  the  abdomen  should  be  explored,  the  umbilical, 
the  inguinal,  and  femoral  regions  being  examined  for  hernia. 

When  the  lateral  regions  are 
examined,  both  hands  should  be 
employed,  one  being  slipped 
under  the  body  so  as  to  make 
forward  pressure  between  the  last 
rib  and  iliac  crest,  thus  pushing 
forward  the  structure  against  the 
examining  hand  in  front. 

At  times  it  may  be  of  service 
to  examine  in  the  knee-elbow 
position,  or  with  the  patient 
standing  and  leaning  forward, 
supporting  himself  with  the  hands 
by  a  table  or  chair.  If  he  is  very 
fat,  it  is  often  useful  to  have  him 
turn  partly  on  the  side,  thus 
' '  spilling ' '  the  intestines  and  fatty 
abdominal  walls  away  from  the 
region  under  investigation. 

Digital  rectal  and  vaginal  ex- 
amination are  very  necessary  in 

manv  cases,  especiallv  when  the 

1      •    '      •         •,       i    J     •       ii.       1  Fisr.  17. — Reinforced   palpation. 

lesion    IS    situated    m  the    lower  ^     '  '     ' 

third  of  the  abdomen.  Rigidity  of  one  or  both  of  the  recti  muscles 
is  of  great  diagnostic  importance,  being  significant  of  peritoneal  irri- 
tation, local  peritonitis  (if  one  muscle  be  involved),  or  general  peri- 
tonitis if  both  recti  and  all  the  abdominal  muscles  are  afTected. 

Occasionally  a  rigid  rectus  is  found  on  the  side  of  a  pneumonia 
or  diaphragmatic  pleurisy. 

The  upper  segments  of  one  or  both  recti  may  be  rigid  in  abscess 
of  the  liver,  or  in  subphrenic  abscess,  or  of  the  right  rectys  in  acute 
cholecystitis;  the  right  rectus,  especially  the  lower  segment,  in 
appendicitis;  and  the  left  rectus  in  diverticulitis,  or  in  left-sided 
pelvic  inflammation. 

Mensuration  of  the  circumference  of  the  abdomen  at  the  level  of 
the  umbilicus  and  of  the  length  of  its  anterior  wall  from  the  ensiform 


52  DISEASES    OF   THE    STOMACH    AXD    IXTESTINES 

to  the  symphysis,  are  of  use  in  noting  the  increase  of  ascites  or  the 
growth  of  a  large  tumor.  An  uneven  protuberant  surface  is  char- 
acteristic of  a  malignant  growth ;  an  even  surface  is  more  often  found 
in  benignant  neoplasms  or  intussusception.  A  fecal  tumor  can 
usually  be  indented  and  as  the  finger  is  raised  the  intestinal  wall 
slips  from  the  mass. 

Percussion  of  the  Abdomen. — With  the  exception  of  pulmonary 
resonance,  which  we  note  in  defining  the  upper  limits  of  the  stomach 
and  liver,  and  splenic  and  hepatic  dulness,  the  normal  abdomen  is 
tvmpanitic.  From  the  presence  of  food  in  the  stomach  or  fecal 
accumulation  in  the  intestines  there  are  variations,  with  resulting 
dulness  or  even  flatness.  The  percussion  note  over  the  sigmoid 
flexure  and  lower  part  of  the  descending  colon  is  quite  frequently 
dull,  owing  to  the  tendency  to  fecal  accunmlation  in  these  regions. 

In  general,  we  mav  say  that  the  pitch  of  the  resonant  note  varies 
w'ith  the  size  of  the  air  space  and  the  degree  of  tension  of  the  con- 


Simple  percussion. 


taining  cavity;  the  smaller  the  air  space  and  the  greater  the  tension, 
the  higher  is  the  pitch.  Hence,  the  empty  stomach  and  colon  would 
afford  a  lower  pitched  note  than  the  small  intestine. 

The  presence  of  food  and  liquid  in  the  stomach  modifies  the 
results  of  percussion,  as  do  also  feces  in  the  large  intestine.  For 
example,  with  an  empty  stomach  we  have  tympanites;  and  then 
quite  frequently  a  change  in  note  over  the  transverse  colon  to  dulness 
or  even  flatness;  or  with  the  partially  full  stomach  and  empty  intes- 
tine, tympanites  above,  then  dulness  or  flatness  over  the  contents 
and  intestinal  tvmpanites  below.  It  is  well,  therefore,  to  have  the 
large  intestine  cleared  out  by  enema  before  examination.  Practically 
we  find  in  many  cases  stomach  tympanites  with  change  in  note  over 
the  colon  due  to  some  contents. 

Among  the  best  methods  of  percussion  are  simple  percussion 
with  the  finger  or  hammer,  flicking  percussion,  auscultatory  per- 
cussion, and  the  "scratch  method"  of  auscultation. 


GENERAL   METHODS    OF    PHYSICAL   EXAMINATION 


53 


In  simple  percussion,  the  middle  finger  of  the  left  hand  should 
be  laid  flat  on  the  abdomen  (the  pleximeter)  and  the  mid-finger  of 
the  right  hand,  bent  at  right  angles,  should  be  employed  as  the  plexor, 
as  depicted  in  Fig.  i8.  The  other  fingers  and  thumb  should  be 
folded  into  the  palm  of  the  hand. 


Fig.  19. — Percussion  hammer. 

In  Fig.  19  is  shown  the  method  with  the  percussion  hammer  and 
the  correct  position.  The  finger  is  preferable  as  a  pleximeter,  as 
the  rubber  instruments  interfere  with  the  sounds. 

"Flicking  percussion"  is  useful  in  detecting  slight  degrees  of 
dulness. 


Fig.  20. — Flicking  metliDd  of  pL-rcussiiJU. 

The  forefinger  or  middle  finger  of  the  left  hand  should  be  placed 
nail  downward  on  the  surface;  the  middle  finger  of  the  right  hand  is 
well  flexed,  so  that  the  nail  is  pressed  against  the  palmar  surface  of 
the  thumb.  It  is  then  suddenly  allowed  to  escape,  so  as  to  strike 
sharply  against  the  palmar  surface  of  the  finger  lying  on  the  abdomen 
(Fig.  20). 


54  DISEASES   OF  THE   STOMACH  AND   INTESTINES 

Auscultatory  percussion  is  probably  of  greatest  value  in  outlining 
contiguous  air-containing  viscera. 

The  stethoscope  is  placed  over  the  organ  and  the  normal  note 
secured  by  percussion  close  to  the  instrument.  Then  percussion  is 
carried  out,  beginning  at  some  distance,  from  above,  below,  and 
laterally,  and  the  change  of  note  observed. 

This  method  and  the  "scratch"  method  will  be  described  later 
in  outlining  the  position  of  the  stomach  and  intestines. 

If  the  percussion  note  of  a  deep-seated  mass  is  to  be  elicited,  the 
pleximeter  finger  must  be  pressed  slowly  and  firmly  down  in  order 
to  push  aside  or  compress  air-coils  of  intestine  which  would  mask 
the  note. 

If  dulness  is  present  where  it  should  not  exist,  it  should  be 
ascertained  whether  it  disappears  or  shifts  with  changes  in  the 
position  of  the  patient,  i.  e.,  whether  it  is  fluid. 

If  the  distention  is  due  to  ascites  (fluid) ,  the  center  of  the  abdomen 
is  flattened  and  the  lateral  and  dependent  portions  bulge  outward, 
providing  the  fluid  is  not  excessive.  If  it  is  very  great,  the  abdomen 
is  arched  and  prominent,  the  umbilicus  is  bulging  or  stretched,  and 
the  shape  is  not  changed  when  the  posture  is  altered. 

On  percussion,  the  flanks  are  dull  and  the  center  of  the  abdomen 
tympanitic,  as  the  intestines  float  to  the  highest  point.  Unless  the 
quantity  of  fluid  is  excessive  the  line  of  dulness  changes  its  position, 
as  the  patient  is  turned  on  the  side  the  fluid  gravitating  to  the  lowest 
point  and  being  replaced  by  the  tympanitic  intestine.  The  upper 
flank,  previously  dull,  is  now  tA^mpanitic.  If  a  small  amount  of  fluid 
is  suspected,  percussion  in  the  umbilical  region  in  the  knee-elbow 
position  will  give  dulness,  when  it  was  tympanitic  in  the  dorsal 
position. 

Fluctuation  may  be  elicited  if  there  is  considerable  fluid. 

The  ulnar  edge  of  a  nurse's  or  assistant's  hand  should  be  pressed 
firmly  on  the  linea  alba,  to  cut  off  muscular  vibrations. 

One  hand  of  the  examiner  is  placed  upon  one  lateral  abdominal 
wall,  while  he  should  tap  sharply  with  the  fingers  on  the  opposite  side. 
If  fluid  is  present,  a  transmitted  wave — at  times  visible — will  be 
felt  by  the  palpating  hand. 

With  tumors,  enlargement  of  the  abdomen  is  not  symmetric. 
Percussion  does  not  show  the  uniform  resonance  of  gas  nor  the 
lateral  dulness  and  central  tympanites  of  fluid,  and  palpation  dem- 
onstrates the  solidity  of  the  mass. 

With  gas,  the  abdomen  is  arched  and  tense,  universally  tym- 
panitic, and  fluctuation  cannot  be  obtained. 

Sources  of  Error. — The  segments  of  the  recti  muscles  when 
contracted  may  simulate  a  small  tumor. 

By  insinuating  the  tips  of  the  fingers  under  the  edge  of  the 
apparent  tumor  and  having  the  patient  raise  the  head  and  shoulders, 
the  muscle  is  felt  to  contract  and  thicken. 


Fig.  21. — Relations  of  the  viscera.     Anterior  view:   L,  L,  Lungs;  A,  heart;  B, 
liver;  C,  stomach;  x,  gall-bladder;  D,  colon;  E,  small  intestine. 


/ 


Fig.  22. — ^Relations  of  the  viscera.     Posterior  view. 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION  55 

A  localized  contraction  of  the  abdominal  muscles  or  a  persistent 

gaseous  distention  of  a  portion  of  the  intestines  ("phantom"  tumor) 

may  be  deceptive.     These  occur,  as  a  rule,  in  hysteric  women  and 

•  are  dull  or  tympanitic,  depending  on  the  above  conditions.     They 

disappear  during  rapid  forced  respiration  or  under  anesthesia. 

Fitz  believes  that  some  "phantom"  tumors  are  congenital  or 
acquired  dilatation  of  the  colon. 

Auscultation  of  the  Abdomen. — Sounds  in  the  Abdominal 
Cavity. — In  the  healthy  intestines  there  are  always  bubbling  or 
gurgling  sounds  heard  on  auscultation.  The  entire  absence  of  sound 
is  significant  of  intestinal  paresis. 

With  mechanic  obstruction  the  sounds  are  usually  increased  in 
intensity  and  number. 

In  intestinal  paresis,  usually  due  to  peritonitis,  the  heart  and 
respiratory  sounds  may  be  audible  over  the  entire  abdomen.  This 
is  not  true  in  tympanites  due  to  other  causes.  Crepitation  or  friction 
sounds  are  at  times  heard  in  peritonitis,  as  in  perihepatitis  in  the 
right  hypochondrium,  or  in  the  left  h^^pochondrium  with  perisplenitis. 

The  venous  hum  or  aneurismal  bruit  of  abdominal  aortic  aneurism 
can  be  appreciated,  or  occasionally  a  venous  hum  over  the  liver  from 
pressure  on  the  vena  cava.  If  pregnancy  is  present,  there  are  the 
fetal  heart  sounds.  The  sounds  over  the  stomach  are  of  little 
diagnostic  value,  except  the  duration  of  the  swallowing  sound. 

TOPOGRAPHIC  ANATOMY 

The  position  and  relations  of  the  stomach  and  intestines  have 
been  described,  but  for  the  purpose  of  physical  diagnosis  we  must 
briefly  refer  to  the  normal  relations  of  the  other  abdominal  viscera. 

In  Fig.  21  are  depicted  diagram.matically  the  relations  of  the 
organs  on  the  anterior  surface  of  the  body,  and  in  Fig.  22  the  relations 
on  the  posterior  surface. 

The  Liver. — The  general  shape  is  that  of  a  wedge  with  its  base 
in  the  right  hypochondrium,  the  upper  surface  lyhig  in  relation  to 
the  vault  of  the  diaphragm,  and  its  lower  surface  with  the  stomach, 
duodenum,  gall-bladder,  transverse  colon,  and  small  intestines; 
its  anterior,  lateral,  and  posterior  portions  are  in  relation  with  the 
abdominal  parietes  and  lower  right  ribs. 

Delimitation  of  the  Normal  Liver. — Mark  a  point  i  (Fig.  23)  at 
the  lower  border  of  the  fifth  rib,  between  the  left  parasternal  and 
mammillary  lines,  or  about  2  to  2h  inches  from  the  left  edge  of  the 
sternum. 

Point  2  lies  in  the  fourth  right  intercostal  space  in  the  mammillary 
line.  From  2  to  i  draw  a  connecting  line,  slightly  convex  upward 
on  the  right  half  and  concave  on  the  left,  curving  down  at  the  lowest 
point  to  the  base  of  the  ensiform  appendix. 

From  2  draw  a  line  nearly  horizontally  to  the  right  and  pos- 
teriorly, which  should  cut  the  midaxillary  line  in  the  seventh  space 


56 


DISEASES    OF   THE    STOMACH   AND    INTESTINES 


and  the  scapular  line  in  the  ninth  space,  to  the  midspinal  Hne.  This 
Hne,  front,  side,  and  back,  corresponds  to  the  upper  border  of  the 
Hver. 

To  dehmit  the  lower  border,  mark  point  4  in  the  median  Hne 
(linea  alba)  about  a  hand-breadth  (3^  to  4  inches)  below  the  base 
of  the  ensiform  process  of  the  sternum. 

]Mark  point  3  at  the  lower  edge  of  the  ninth  right  costal  cartilage, 
and  another  point  5  at  the  edge  of  the  left  costal  arch  on  a  level  with 
the  lower  border  of  the  sixth  rib.  A  line  should  then  be  drawn  from 
3  to  4  upward  and  to  the  left.  At  4  is  indicated  the  notch  between 
the  liver  lobes.  From  4  a  shghtly  curved  hne  to  i ,  passing  through 
5,  should  next  be  drawn.  The  line  from  3  to  i  indicates  the  lower 
anterior  border  of  the  organ. 


Fig.  23. — Delimitation  of  the  normal  liver  (diagrammatic):  G,  Gall-bladder. 


From  point  3  draw  a  Hne  backward  and  to  the  right,  cutting  the 
tenth  intercostal  space  in  the  midaxillary  line,  from  which  point  it 
joins  the  spine  at  a  level  of  the  eleventh  rib  (Fig.  24).  This  line 
demarks  the  lower  border  of  the  liver  laterally  and  posteriorly,  and 
is  a  continuation  of  the  anterior  inferior  border. 

This  illustration  shows  diagrammatically  the  relations  of  the 
lower  borders  of  the  lung,  .pleura,  and  liver  in  the  midaxillary  Hne. 

The  left  lobe  lies  to  the  left  of  the  linea  alba  and  extends  nearly 
to  the  nipple,  the  notch  lying  in  the  midline.  In  the  right  mammil- 
lary  line  the  liver  extends  from  just  below  the  level  of  the  nipple  to 
the  costal  margin. 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION  57 

The  horizontal  shadings  in  Fig.  23  show  the  portion  of  liver 
overlapped  by  lung,  and  the  vertical  shadings,  that  overlapped  by 
the  heart. 


Fig.  24. — Lower  border  of  liver  (midaxillary  line). 

The  gall-bladder,  which  is  pear  shaped,  lies  just  internal  to  the 
ninth  right  costal  cartilage. 

PHYSICAL  EXAMINATION  OF  THE  LIVER  AND  GALL-BLADDER 

Inspection. — The  method  advocated  by  M.  Knapp  I  have  found 
most  practical.  The  patient  stands  with  the  abdomen  uncovered 
facing  a  good  light,  the  examiner  slightly  to  the  patient's  right,  so 
as  not  to  interfere  with  the  exposure  to  light.  The  lower  edge  of 
the  enlarged  liver  shows  on  the  abdomen  as  a  linear  transverse 
shadow,  moving  up  and  down  with  respiration  and  being  especially 
prominent  at  the  close  of  expiration,  when  there  is  a  sudden  check 
to  the  movement.  Pulsation  can  occasionally  be  observed.  Ex- 
treme enlargement  may  cause  fulness  in  the  right  hypochondrium. 

An  enlarged  gall-bladder  can  be  appreciated  in  the  same  manner. 
Inspection  may  also  be  made  with  the  patient  in  the  dorsal  position, 
the  examiner  stooping  so  as  to  bring  the  eyes  on  a  level  with  the 
abdomen. 


58  DISEASES   OF  THE   STOMACH  AND   INTESTINES 

Palpation. — The  head  and  shoulders  should  be  slightly  raised 
and  the  knees  and  thighs  flexed,  the  patient  being  in  the  dorsal 
position.  The  examiner,  sitting  on  the  right  side  of  the  patient, 
should  lay  the  right  hand  flat  on  the  abdomen  below  the  right  costal 
arch,  the  fingers  pointing  upward  and  obliquely  inward  just  to  the 
right  of  the  right  rectus.  Depress  the  fingers  and  feel  for  the  resistant 
edge  of  the  liver.  The  patient  should  be  directed  to  take  deep  respira- 
tions, and  by  pressing  inward  and  upward  with  the  fingers  the  edge 
of  the  organ  can  be  felt  to  move  up  and  down. 

As  the  liver  may  be  enlarged,  palpation  for  its  lower  edge  must 
be  begun  from  the  level  of  the  umbilicus  upward.  It  is  often  neces- 
sary to  feel  for  the  notch  of  the  gall-bladder  or  round  ligament  to 
determine  whether  it  is  the  edge  of  the  liver  which  is  felt  on  palpation. 
One  should  note  whether  the  edge  is  sharp  or  thick,  or  smooth  or 
irregular.     In  some  cases  with  thick  abdominal  walls  the  liver  may 


Fig.  25. — Spilling  the  liver. 

be  "spilled"  against  the  latter  by  turning  the  patient  on  the  right 
side,  as  in  Fig.  25,  thus  rendering  palpation  more  easy.  The  hand 
in  this  case  may  be  in  the  reversed  position. 

The  surface  of  the  liver  should  be  palpated,  the  left  lobe  in  the 
epigastrium  and  the  portion  projecting  below  the  ribs,  if  it  be  enlarged. 

One  should  observe  whether  it  is  rough,  smooth,  nodular,  or 
whether  large  tumor-like  masses  are  present ;  also  whether  it  is  hard 
or  soft  and  fluctuating;  or  if  there  is  a  thrill  (hydatid),  or  friction 
during  respiration,  or  pulsation.  If  the  abdomen  is  distended  the 
"dipping"  method  of  palpation  may  be  necessary. 

The  empty  gall-bladder  is  not  palpable.  If  distended  it  feels  like 
a  smooth  pear-shaped  tumor,  moves  with  respiration,  and  is  movable 
laterally,  unless  there  are  adhesions. 

If  malignant  growth  is  present,  the  gall-bladder  is  irregular  and 
nodular.  If  there  are  many  gall-stones,  Hutchinson  describes  the 
feel  as  of  a  "bag  of  nuts." 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION  59 

Percussion  of  Liver  and  Gall-bladder. — For  anterior  and 
lateral  percussion  the  patient  should  lie  down;  for  percussion  pos- 
teriorly he  should  be  sitting  or  standing. 

The  upper  part  of  the  right  lobe  is  overlapped  by  the  lung,  and 
of  the  left  lobe,  a  small  area  is  covered  by  the  left  lung  and  heart. 

Percussion  over  the  covered  part  gives  impaired  pulmonary 
resonance,  or  modified  dulness  (deep,  relative,  or  covered  hepatic 
dulness).  The  part  in  contact  with  the  parietes  gives  absolute 
dulness  (superficial  or  exposed  dulness). 

It  is  necessary  to  delimit  the  entire  area.  Percuss  downward, 
first  in  the  mammillary  line,  beginning  at  the  second  intercostal 
space;  then  in  the  midaxillary  line  from  the  fourth  interspace,  and 
in  the  scapular  line  from  the  angle  of  the  scapula.  Percussion  should 
then  be  made  from  below  upward,  in  the  midline  from  the  umbilicus 
and  from  lateral  and  posterior  points  below  the  ribs. 

Covered  Hepatic  Dulness. — Strong  percussion  should  be  employed, 
commencing  above  in  the  areas  noted,  and  watching  for  the  change 
from  pure  pulmonar}^  resonance  to  impaired  resonance,  which 
denotes  the  presence  of  the  liver.  Impaired  resonance  is  found 
normally  in  the  fourth  space  in  the  mammillary  line;  in  the  seventh 
space  in  the  midaxillary  line;  and  in  the  ninth  space  in  the  scapular 
Hne. 

Upper  Limit  of  Exposed  (Absolute)  Hepatic  Dulness. — Gentle 
percussion  should  then  be  employed  and  normally  absolute  liver 
dulness  appears  in  the  mammillary  line  at  the  sixth  rib;  midaxillary 
line  at  the  eighth  rib.;  and  in  the  scapular  line  at  the  tenth  rib. 

Lower  Limit  of  Hepatic  Dulness. ^Gentle  percussion  along  the 
lines  previously  indicated  from  below  upward  will  differentiate 
between  tympanites  and  hepatic  dulness.  The  lower  limit  normally 
is  in  the  median  line  anteriorly  a  hand-breadth  (3J  to  4  inches)  below 
the  ensiform;  in  the  mammillary  line,  the  tenth  space.  In  the 
scapular  line,  it  joins  the  dulness  of  the  right  kidney. 

The  vertical  width  of  liver  dulness  is  normally  in  the  mammillary 
line  4  inches;  in  the  midaxillary,  6  inches;  in  the  scapular,  3. inches. 

Percussion  of  the  Gall-bladder. — This  is  only  possible  when  it  is 
distended  x)r  enlarged,  in  which  event  there  is  an  area  of  dulness 
projecting  downward  and  inward  from  the  lower  border  of  the  liver 
and  continuous  with  the  dulness  of  the  latter.  In  some  cases  the 
transverse  colon  may  pass  over  the  neck  of  the  distended  gall-bladder 
and  separate  its  dulness  from  that  of  the  liver  by  a  tympanitic  area. 
This  is  important  to  remember. 

Auscultatory  Percussion  of  the  Liver. — The  stethoscope  should  be 
placed  over  the  middle  of  the  area  of  the  liver  anteriorly,  laterally, 
and  posteriorly,  and  percussion  be  carried  out  on  the' lines  already 
described.  As  a  rule,  simple  percussion  is  sufficient;  but  the  auscul- 
tatory method  is  of  special  value  to  determine  whether  a  tumor  is 
connected  with  the  liver  or  not. 


6o  DISEASES    OF   THE   STOMACH    AND   INTESTINES 

Thus  in  Fig.  26  the  stethoscope  is  placed  over  point  5.  The 
note  over  the  tumor  T  resembles  more  closely  in  intensity  and 
quality  the  percussion  note  over  the  liver  at  C  than  it  does  over  the 
point  A. 

General  enlargement  of  the  liver  may  be  due  to  passive  congestion, 
usually  from  valvular  disease  of  the  heart,  amyloid  disease,  cancer, 
fatty  infiltration,  hypertrophic  cirrhosis,  leukemia,  abscess,  gumma, 

or,  rarely,  Weil's  disease. 

Circumscribed  enlarge- 
ment of  the  liver,  i.  e., 
of  the  left  lobe,  is  usually 
due  to  abscess,  hydatid 
cyst,  gumma,  or  cancer. 

Downward  displace- 
ment of  the  liver  is  caused 
by  various  intrathoracic 
lesions,  such  as  emphy- 
sema, effusions,  etc.,  by 
subphrenic  abscess,  or  as 
a  part  of  a  general  ptosis  of 
Fig.  26.-Tumor  of  liver.  the  viscera.     In  downward 

displacement  the  upper  surface,  especially  of  the  left  lobe,  is  readily 
accessible  to  palpation  and  presents  a  rounded  surface. 

A  prolapsed  liver  does  not  move  as  freely  with  respiration,  on 
account  of  its  separation  from  the  diaphragm. 

The  consistence  of  the  hver  is  somewhat  diagnostic.  It  is 
abnormally  hard,  dense,  and  resistant  in  cirrhosis,  carcinoma, 
amyloid   disease,   or   syphilis. 

A  fluctuating  swelling  at  the  lower  border  may  be  a  distended 
gall-bladder,  abscess,  or  hydatid  cyst. 

The  surface  is  smooth  in  fatty  infiltration  or  degeneration,  in 
passive  congestion,  and  in  amyloid  disease;  it  is  rough  in  tubercular 
peritonitis  and  granular  to  the  feel  in  cirrhosis. 

Hard  nodules,  varying  in  size,  are  suggestive  of  cancer;  smooth, 
elevated  prominences  occur  with  gummata.  A  smooth  projection 
may  be  due  to  abscess  or  cyst. 

Topography  of  the  Pancreas. — The  pancreas  (Fig.  27)  lies 
about  3  inches  above  the  umbilicus,  midway  between  the  navel  and 
the  ensiform  appendix,  corresponding  to  the  level  of  the  second 
lumbar  vertebra. 

It  is  about  6  inches  long  and  lies  deep  in  the  epigastrium,  trans- 
versely across  the  spine,  with  its  head  resting  in  the  cur^^e  of  the 
duodenum  and  its  tail  extending  to  the  spleen.  The  stomach  covers 
it  in  front.  It  is  rarely  accessible  to  direct  examination.  The  head 
of  the  organ  lies  in  close  relation  to  the  inferior  vena  cava,  portal 
vein,  and  common  bile-duct,  which  are  posterior.  A  cancer  or 
growth  of  the  head  of  the  pancreas  may  press  upon  these  blood- 


GENERAL   METHODS    OF    PHYSICAIv   EXAMINATION 


6i 


vessels  and  cause  edema  and  ascites,  or  upon  the  bile-duct  and 
produce  persistent  jaundice. 

Pain,  fatty  diarrhea,  ascites,  glycosuria,  and  jaundice  may  result 
from  pancreatic  disease. 

Physical  Examination. — Normally  the  pancreas  cannot  be  pal- 
pated unless  the  patient  is  extremely  emaciated. 

An  important  physical  sign  of  pancreatic  disease  is  the  presence 
oj  a  tumor  in  the  median  portion  of  the  epigastrium,  midway  between 
the  navel  and  ensiform  process.  It  is  deep  seated  and  often  nothing 
more  than  a  sense  oj  resistance  can  be  appreciated  by  the  palpating 
hand. 


Fig.  27. — The  pancreas. 


The  diseases  in  which  these  conditions  are  present  are  acute 
hemorrhagic  or  suppurative  pancreatitis,  chronic  pancreatitis,  and 
tumor — either  carcinomatous  or  cystic. 

Topography  of  the  Spleen. — The  spleen  is  oval,  flattened  in 
shape,  and  lies  in  the  left  hypochondriac  region,  measuring  on  an 
average  5  by  3  inches.  It  reaches  from  a  point  i^V  inches  from  the 
midspinal  line  posteriorly  nearly  to  the  midaxillary  Hne,  lying  along 
the  ninth,  tenth,  and  eleventh  ribs,  the  long  axis  being  parallel  with 
the  ribs  and  running  obHquely  forward  and  downward,  as  in  Fig.  30. 

The  lower  two-thirds  of  its  outer  surface  lie  against  the  lateral 
abdominal  wall,  and  the  upper  third  is  overlapped  by  the  diaphragm, 
which  separates  it  from  the  lower  border  of  the  left  lung.  The 
diaphragm  lies  above  and  the  left  kidney  posteriorly,  and  it  is  in 
contact  elsewhere  with  the  stomach,  pancreas,  colon,  and  small 
intestine. 


62  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

The  anterior  border  is  sharp  and  indented  by  two  to  four  notches. 

Physical  Examination  of  the  Spleen. — Inspection. — If  the 
spleen  is  greatly  enlarged,  it  may  be  visible  as  a  protuberance  extend- 
ing from  the  left  hypochondrium  downward  and  inward,  moving 
with  respiration. 

Palpation. — With  the  patient  in  the  dorsal  position  and  the 
knees  and  thighs  flexed,  the  examiner  on  the  right  side  of  the  bed 
should  lay  the  right  hand  flat  on  the  abdomen  and  with  the  finger- 
tips exert  pressure,  pushing  obliquely  upward  under  the  left  costal 
margin  at  the  tenth  cartilage.  The  edge  of  the  enlarged  spleen 
can,  as  a  rule,  then  be  felt. 

If  it  is  not  palpable,  then  request  the  patient  to  take  deep  breaths, 
when  the  sharp  edge  of  the  organ,  which  is  smooth  and  usually 
notched,  moving  with  respiration,  will  be  felt  riding  over  the  finger- 
tips and  directed  downward  and  inward. 


Fig.  28. — Examination  of  the  spleen.     "  Spilling  the  spleen." 

The  left  hand  may  be  placed  posteriorly  between  the  ends  of  the 
tenth  and  eleventh  ribs  and  firm  pressure  be  made,  so  as  to  tilt  the 
organ  forward  and  thus  make  palpation  more  easy.  Normally  the 
spleen  cannot  be  felt. 

If  the  organ  is  enlarged  a  depression  or  space,  into  which  the 
finger-tips  can  be  sunk,  can  be  detected  at  the  posterior  border  of 
the  enlarged  spleen  between  it  and  the  erector  spinae. 

An  excellent  method  of  palpation  of  the  spleen  is  shown  in  Fig.  28. 
By  turning  the  patient  on  the  right  side,  combined  with  posterior 
pressure,  palpation  is  rendered  easier. 

It  is  often  necessary  to  differentiate  between  tumor  of  the  left 
kidney  or  spleen. 

The  spleen  is  oval,  moves  with  respiration,  is  notched,  has  a  sharp 
edge,  a  gap  is  present  between  it  and  the  lumbar  muscles,  and  it  has 
no  tympanitic  resonance  over  it. 


GENERAL    METHODS    OF    PHYSICAL   EXAMINATION 


63 


The  kidney  is  reniform  in  shape  and  rounded,  has  no  sharp  edge 
or  notch,  and  is  overlaid  by  tympanitic  resonance  (Fig.  29). 

Percussion  of  the  Spleen. — The  patient  may  be  recumbent, 
partially  turned  to  the  right,  midway  between  the  dorsal  and  right 
lateral  position,  with  the  left  arm  extended  over  the  head;  or  the 
examination  may  be  m.ade  in  the  sitting  posture.  Percussion  should 
be  light,  except  over  the  posterior  portion  near  the  kidney. 


:^f:; 

I^H 

1    OF   LUN  G. 

P>i  ^^V 

'•^MARGIN 

OP  RIB3. 

^^f. 

jmKf     J^^r 

L 

>^"' 

^^^0ii^'- 

1 

r 

1 

.   'i'fi*'  ■  ..  i« 

■i^r^ 

i^., 

Fig.  29. 


-S,  Tumor  of   spleen;    K,  tumor  of  kidney, 
by  tympanitic  colon. 


Kidney  tumor  overlaid 


It  should  be  carried  out  along  the  lines  .4,  B,  C,  D  in  Fig.  30. 
Anterior  percussion  at  the  costal  margin  along  the  tenth  rib,  along 
A  until  the  tympanites  of  the  stomach  is  replaced  by  dulness  usually 
at  midaxillary  line.  From  above  percuss  along  B,  commencing  at 
the  level  of  the  angle  of  the  scapula  midway  between  the  posterior 
axillary  and  scapular  lines,  passing  vertically  downward  until  pul- 
monary resonance  is  impaired,  generally  at  ninth  rib. 

Percuss  from  below  upward  along  line  C,  commencing  below 
the  border  of  the  ribs,  in  or  sHghtly  posterior  to  the  posterior  axillary 
line,  and  passing  upward  until  tympanites  becomes  dull,  usually 
at  eleventh  rib. 

Posteriorly  percuss  strongly  from  midspinal  line  at  level  of  tenth 
rib  and  along  the  latter. 

Splenic  dulness  should  commence  i^  inches  from  the  median 
spinal  line.  It  is  difficult  to  determine.  The  area  of  splenic  dulness 
is  oval,  2  to  2^  inches  by  3  to  3I  inches.  Dulness  of  over  3I  inches, 
on  vertical  percussion,  shows  enlargement. 


64 


DISEASKS    OF   THE    STOMACH    AND   INTESTINES 


Pleuretic  effusion,  consolidation  at  the  left  base,  and  fecal  accu- 
mulation in  the  splenic  flexure,  may  obscure  percussion  of  the  spleen. 
Palpation  is  the  most  important  method  and  the  most  accurate. 

Acute  enlargement  of  the  spleen  occurs  with  infectious  diseases, 
such  as  typhoid,  malaria,  etc.,  and  in  septic  processes;  chronic 
enlargement,  with  leukemia,  malaria,  cirrhosis  of  the  liver,  amyloid 
disease,  pernicious  anemia,  etc.  The  organ  m^ay  be  displaced 
downward  by  intrathoracic  pressure. 


Fig.  3o.^Lines  for  percussion  of  spleen. 

Abscess,  carcinoma,  or  hydatids  may  cause  an  unequal  enlarge- 
ment. Liver  and  spleen  may  be  enlarged  together  in  passive  con- 
gestion, cirrhosis  of  the  liver,  leukemia,  and  in  amyloid  disease. 

A  floating  spleen  may  occur  as  a  result  of  congenital  laxity  of 
its  ligaments  or  to  overstretching  from  the  increased  size  or  weight. 
It  may  be  part  of  a  visceroptosis,  usually  in  women.  It  is  recognized 
by  its  mobility,  shape, '  sharp  edge,  and  notches. 

Topography  of  the  Kidneys. — The  two  kidneys  lie  against  the 
posterior  abdominal  wall,  one  on  each  side  of  the  spinal  column,  in 
beds  of  fat  and  connective  tissue.  They  are  of  reniform  shape. 
The  upper  end  of  the  right  kidney  is  in  contact  with  the  liver,  and 


GENERAL   METHODS    OF    PHYSICAL   EXAMINATION 


65 


the  left  kidney  with  the  spleen.  They  are  retroperitoneal,  the 
ascending  and  descending  colon  respectively  lying  in  relation  in 
front.  The  right  kidney  lies  about  ^  inch  lower  than  the  left.  Each 
organ  is  about  4  inches  long,  2  to  2^  inches  in  breadth,  and  i  inch 
thick. 

Surface  Relations  of  the  Kidneys. — Draw  a  horizontal  line  through 
the  upper  margin  of  the  unibiHcus;  prolong  the  mammillary  lines  on 
each  side  downward  until  they  intersect  this  horizontal  line.  The 
points  of  intersection  lie  about  3  inches  on  each  side  of  the  median 
line. 

From  the  intersections  measure  upward  i  inch  on  the  right  and 
1 5  inches  on  the  left  mammillary  line,  and  draw  on  each  side  a  short 


Fig.  31. — Anterior  surface  of  kidneys. 

horizontal  line.     The  lower  ends  of  the  kidneys  He  at  these  levels 

(Fig-  30- 

One  can-  measure  3  inches  on  each  side  along  the  horizontal  line 
and  then  upward,  without  drawing  the  mammillary  Hne.  The 
kidneys  extend  upward  and  inward  about  4  inches,  one-third  to  the 
outer  side  and  two-thirds  to  the  inner  side  of  the  vertical  lines. 

Posterior  Surface  Relations  of  the  Kidneys. — Draw  a  horizontal 
line  across  the  back  at  the  level  of  the  tip  of  the  spine  of  the  eleventh 
dorsal  vertebra ;  a  second  line  at  a  level  of  the  tip  of  the  spine  of  the 
third  lumbar  vertebra.  On  each  side  draw  a  vertical  line  from  the 
upper  to  the  lower  horizontal  Hues,  i  inch  from  the  median  line  of 
the  spine,  and  second  vertical  lines  2-}  inches  away  from  the  first 
vertical  lines.  Within  these  outer  parallelograms  lie  the  kidneys 
(Fig.  32). 


66 


DISEASES    OF   THE   STOMACH   AND   INTESTINES 


The  lower  ends  of  these  organs  lie  from  i  to  i^  inches  above  the 
iliac  crests,  the  right  J  inch  lower  than  the  left.  About  a  third  of  the 
upper  ends  are  covered  by  the  eleventh  and  twelfth  ribs;  the  liver 
overlaps  the  right  kidney  and  the  spleen  the  left. 

Physical  Examination  of  the  Kidneys. — Inspection  is  seldom 
of  service;  palpation  is  most  valuable;  percussion  is  often  uncertain. 

Inspection. — A  large  tumor  of  the  kidneys  may  be  visible  in  the 
anterior  lumbar  regions,  extending  into  the  umbilical  region,  with 
outward  bulging  of  the  ribs  on  the  affected  side,  such  as  in  the  case 


/ 


\ 


Fig.  32. — Posterior  surface  relations  of  kidneys:  A,  Lower  border  of  lungs; 
B,  level  of  spine  of  eleventh  dorsal  vertebra;  C,  lower  border  of  liver;  Z?,  level 
of  spine  of  third  lumbar  vertebra;  E,  colon. 

of  sarcoma,  hydronephrosis,  or  cyst.  A  perinephritic  abscess  may 
become  visible  as  a  swelling  in  the  posterior  lumbar  region. 

Palpation. — This  is  most  important.  There  are  several  methods 
described,  of  which  the  two  following  are  the  most  practical: 

Method  I. — The  patient  lies  in  the  dorsal  position,  with  the  knees 
and  thighs  flexed,  and  the  head  is  slightly  raised  to  secure  perfect 
relaxation.  If  the  right  kidney  is  to  be  examined,  the  left  hand  is 
slipped  under  the  back,  so  that  it  rests  on  the  two  lower  ribs  and  the 
lumbar  space  below  thern.  The  right  hand  is  laid  flat  on  the  abdomen 
in  front,  resting  below  the  costal  margin  to  the  outer  side  of  the 
rectus,  as  in  Fig.  33. 


GENERAL   METHODS    O^   PHYSICAIv   EXAMINATION  67 

The  patient  should  take  deep  and  slow  respirations,  and  during 
expiration  firm  pressure  should  be  made  with  the  fingers  in  front 
against  posterior  counterpressure,  so  that  the  kidney  may  be  grasped 
between  the  hands. 

If  the  kidney  is  normal  in  position  and  size,  the  extreme  lower 
edge  can  be  felt  if  the  abdominal  walls  are  not  too  thick.  If  the 
lower  quadrant  of  the  organ  can  be  clearly  palpated,  it  may  be 
considered  a  movable  kidney  (of  the  first  degree). 

Various  classifications  of  mobility  have  been  given,  some  con- 
sidering the  organ  when  palpable  in  half  its  extent,  mobility  of  second 
degree ;  entirely  palpable,  mobility  of  third  degree ;  and  when  descend- 
ing into  the  abdominal  cavity,  mobility  of  fourth  degree.  Others 
consider  it  movable  if  the  entire  length  be  accessible,  especially  if  it 


Fig-  33- — Palpation  of  kidney  (older  method)." 

can  slip  down  as  far  as  the  horizontal  umbilical  fine ;  and  if  it  can  be 
displaced  below  this  or  across  the  abdomen,  as  a  floating  kidney. 

I  believe  that  any  kidney  which  can  be  palpated  to  one-fourth 
of  its  extent  should  be  considered  movable,  and  the  subdivision  into 
various  degrees  of  mobility  to  be  excellent.  A  movable  kidney 
from  strain  or  traumatism  is  comparatively  rare.  Occasionally 
we  find  a  congenital  floating  kidney  with  no  visceroptosis.  As  a 
rule,  I  believe  that  in  about  95  per  cent,  of  cases  of  movable  kidney 
the  condition  is  merely  part  of  a  ptosis  of  the  abdominal  organs, 
and  it  may  be  considered  to  be  practically  pathognomonic  of  this 
condition.  The  right  kidney  is  most  frequently  movable,  though 
both  may  be  so. 

If  the  kidney  is  not  found  at  its  normal  site,  it  should  be  searched 
for  in  the  abdomen. 


68 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


In  examination  of  the  left  kidney,  the  position  of  the  hands  is 
reversed. 

Method  2. — This  is,  from  personal  experience,  the  most  practical 
method  of  palpation,  and  the  varying  degrees  of  mobility  can  be 
detected  with  greater  ease  than  by  the  method  described. 

For  examination  of  the  right  kidney,  the  patient  sits  up  in  bed, 
and  the  left  hand  of  the  examiner  grasps  the  right  flank,  the  thumb 
resting  under  the  costal  margin,  the  fingers  posteriorly.  The  patient 
breathes  deeply,  or  coughs,  or  bears  down,  and  the  kidney  can  be 
felt  to  slip  down  between  the  thumb  and  fingers,  like  "a  pea  in  a 
pod,  "  or  the  lower  margin  or  part  of  the  kidney  may  be  felt  (Fig.  34). 

If  the  organ  slips  be3^ond  the  thumb  and  fingers  or  is  not  found 
in  its  normal  position,  then  the  left  hand  grasps  the  flank  more 


Fig.  34. — Palpation  of  kidney.     Step  i. 

firmly  and  upward  palpation  is  made  with  the  right  hand,  as  in 
Fig.  35,  the  patient  gradually  assuming  the  semi-oblique  and,  finally, 
the  dorsal  position,  the  final  step,  as  shown  in  Fig.  36. 

A  similar  method  with  the  patient  standing  is  employed  b}' 
Goelet,  but  the  technic  described  seems  preferable. 

For  palpation  of  the  left  kidney,  the  position  of  the  hands  is 
reversed,  the  right  hand  grasping  the  loin  and  the  left  hand  anteriorly. 

Tumors,  hydronephrosis,  and  cysts  of  the  kidney  may  be  detected 
by  palpation  of  the  abdomen,  as  already  described. 

Brewer's  Point. — Tenderness  at  the  costovertebral  angle  is 
diagnostic  of  an  acute  inflammatory  condition  of  the  kidney,  such  as 
infarctions,  etc.,  and  aids  in  differentiation  between  this  condition, 
appendix  adherent  to  the  liver,  and  acute  cholecystitis. 


GENERAL   METHODS    OF    PHYSICAL   EXAMINATION 


69 


Percussion  of  the  Kidney. — The  lower  and  part  of  the  outer  border 
of  the  kidney  may  at  times  be  determined  by  percussion,  comparing 
the  dulness  with  the  tympanitic  note  of  the  colon  which  lies  ante- 
riorly. As  a  rule,  the  thickness  of  the  muscles,  peritoneal  fat,  or 
fecal  accumulation  render  the  results  uncertain. 


Fig-  35- — Palpation  of  kidney.     Step  2.     Patient  in  semi-oblique  posture. 

Position  for  Perctission. — The  patient  may  lie  on  the  abdomen, 
with  one  or  two  pillows  placed  underneath,  to  arch  the  back;  or  on 
the  side,  midway  between  the  lateral  and  prone  position,  the  physician 


Fig.  36. — Palpation  of  kidney.     Step  3  (Unal,.     Patient  in  dorsal  position. 

sitting    facing   the    patient's   back   and   percussing  the    uppermost 
kidney. 

One  should  commence  percussion  in  the  middle  of  the  area  in 
which  the  kidney  Hes   (Fig.  32),  using  heavy  strokes,  and  percuss 


70  DISBASBS    OF   THE    STOMACH   AND   INTESTINES 

outward  until  the  kidney  dulness  is  replaced  by  tympanites;  also 
percuss  downward  in  the  same  way.  Increased  dulness  shows 
enlarged  kidney. 

To  Differentiate  a  Movable  Right  Kidney  from  the  Distended 
Gall-bladder. — The  kidney  is  movable  in  all  directions,  can  be  carried 
downward,  does  not  move  with  respiration.  Tympanites  is  found 
between  it  and  the  costal  margin,  the  shape  is  reniform,  and  it  may 
be  pushed  back  into  its  normal  position. 

The  distended  gall-bladder  moves  with  respiration,  can  only 
be  moved  laterally;  if  pushed  away  from  the  abdominal  wall,  it 
tends  to  resume  its  original  position;  and  there  is  no  tympanites 
between  it  and  the  liver  dulness. 

The  chief  causes  of  enlarged  kidney  are  pyonephrosis,  perine- 
phritic  abscess,  hydronephrosis,  cyst,  echinoccoccus,  carcinoma,  and 
sarcoma. 

An  enlarged  kidney  tends  to  develop  toward  the  front ;  an  abscess, 
posteriorly,  between  the  last  rib  and  the  iliac  crest. 

With  enlarged  kidney,  the  colon  overlays  in  front  of  the  tumor. 
With  splenic  tumor,  this  does  not  occur  (Fig.  29). 

If  in  doubt,  inflate  the  descending  colon  with  air  through  a  colon- 
tube  or  catheter. 


PART  II 
DISEASES  OF  THE  STOMACH 


CHAPTER  V 


METHODS  OF  PHYSICAL  EXAMINATION  OF  THE 
STOMACH 

General  Considerations. — For  an  intelligent  understanding 
of  the  subject,  it  is  necessary  to  briefly  define  those  conditions  which 
constitute  an  abnormality  in  the  position  of  the  stomach  and  to 
differentiate  between  them. 

The  greater  curvature  of  the  normally  distended  stomach  hes 
about  2  to  3  fingers-breadth  (ih-^l  inches)  above  the  umbilicus. 
The  normal  position  of  the  organ  has  been  indicated  in  Chapter  I. 
It  must  be  remembered  that  some  possess  an  abnormally  large 
stomach;  and  that  it  can  only  be  considered  to  be  dilated  if  there 
are  symptoms  associated  which  point  to  this  organ. 

If  there  is  atony  of  the  stomach,  with  motor  insufficiency,  the 
patient  having  gastric  symptoms,  while  the  lower  border  of  the  stomach 
is  de-fined  at  the  level  of  the  umbiHcus  or  below  it,  the  lesser  curvature 
maintaining  its  relations  to  the  diaphragm,  we  may  consider  the 
organ  to  be  dilated.  This  constitutes  the  atonic  type  of  dilatation, 
which  is  extremely  common.  Many  of  this  class  suffer  from  auto- 
intoxication with  nervous  sequelae,  and  are  found  in  great  numbers 
in  our  asvlums  and  among  our  nervous  cases.  Attention  may  be 
diverted  from  the  gastric  symptoms  and  they  may  even  be  slight. 

As  a  result  of  pyloric  spasm,  or  benign  or  mahgnant  stricture  of 
the  pylorus,  or  any  obstruction  in  the  pyloric  region  interfering  with 
the  egress  of  the  gastric  contents,  we  have  the  so-called  stenotic 
type  of  dilatation  of  the  stomach. 

In  these  cases  the  lesser  curvature  retains  its  relation  to  the 
diaphragm,  while  the  lower  border  extends  to  the  umbilicus  or  below . 
it,  and  gastric  symptoms  are  present  to  a  marked  degree  and  of  a 
special  type. 

With  gastroptosis  (prolapse  of  the  stomach)  the  suspensory 
ligaments  of  the  stomach  are  relaxed  and  the  entire  organ  sinks, 
the  lesser  curvature  as  well  as  the  greater.  In  aggravated  cases  the  lesser 
curvature   looks   inward  to   the   right,   and   the   greater  curvature 

71 


72  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

outward  to  the  left.  The  pylorus  may  often  lie  below  the  level  of 
the  umbiHcus.  With  this  condition,  movable  kidney — especially 
of  the  right  organ — is  present,  and  may  practically  be  considered 
pathognomonic  in  my  opinion,  as  only  in  about  5  per  cent,  or  less 
of  cases  is  mobility  due  to  strain  or  injur}*.  The  congenital  floating 
kidney,  without  ptosis  of  other  viscera,  is  excessively  rare. 

There  may  be  various  degrees  of  gastroptosis,  a  loop-shape,  or 
even  a  vertical  stomach  similar  to  that  of  the  fetal  period,  which  are 
pictured  in  the  chapter  on  Gastroptosis.  The  change  in  position  of 
the  lesser  curvature  is,  therefore,  diagnostic  of  gastroptosis,  and  not  the 
position  of  the  lower  border  of  the  stomach.  The  presence  of  movable 
kidney  is  also  diagnostic. 

It  seems  advisable  to  describe  the  methods  generallv  employed, 
and  at  the  end  of  the  chapter  to  briefly  summarize  those  which  are 
of  most  practical  value. 

Preparation  of  the  Patient. — On  the  day  or  night  previous 
to  examination,  the  bowels  should,  if  possible,  be  thoroughly  emptied 
by  a  cathartic.  If  there  is  much  tympanites,  it  should  be  relieved 
by  a  hot  enema  of  about  i  liter  (i  quart)  of  normal  saline  solution 
or  soapsuds  and  water;  or,  if  the  condition  is  marked,  then  by  entero- 
clysis  at  110°  to  120°  F.  with  a  recurrent  tube  (Kemp's)  or  two 
catheters.     This  carries  off  the  gas  in  a  satisfactory  manner. 

The  patient  should  be  examined  in  the  dorsal,  semi-oblique,  and 
standing  positions. 

Inspection. — Examination  in  the  dorsal  position  should  first 
be  made. 

A  recognizable  bulging,  distinct  from  the  epigastrium,  especially 
if  it  occur  in  the  umbilical  or  hypogastric  region,  may  be  due  to  a 
dilated  stomach;  the  epigastrium  under  these  conditions  is  usually 
hollow  and  depressed.  Inspection  is  often  of  assistance  in  thin 
patients,  especially  after  artificial  distention  of  the  stomach  with 
carbonic  acid  gas. 

Peristaltic  movements  of  the  dilated  stomach  are  at  times 
observed. 

Kussmaul  has  noted  very  active  peristaltic  movements  in  the 
dilated  stomach  (peristaltic  unrest),  the  waves  passing  from  the 
linea  alba  below  the  umbilicus  in  an  upward  direction  and  to  the 
right  to  the  lower  margin  of  the  liver.  This  is  found  present  in  cases 
in  which  stenosis  of  the  pylorus  exists. 

We  can  facilitate  inspection  by  placing  the  patient  upon  a  raised 
table,  the  head  toward  the  window,  the  shades  being  arranged  so 
that  the  light  enters  on  a  plane  only  slightly  above  that  of  the  patient, 
and  is  directed  from  tbe  head  toward  the  feet.  The  examiner, 
standing  toward  the  foot  of  the  table  and  bending  from  side  to  side, 
can  at  times  make  out  shadows  cast  by  the  inequalities  of  the  abdo- 
men. The  shadows  move  with  respiration.  By  this  method  the 
size,  shape,  and  position  of  the  stomach  can  often  be  made  out. 


METHODS    OF    PHYSICAL    EXAMINATION    OF   THE    STOMACH  73 

Knapp  places  the  patient  in  the  same  position,  but  stands  at  the 
side  or  at  the  shoulders,  and  brings  his  eyes  down  to  the  level  of  the 
abdomen  and  observes  the  respiratory  waves  passing  over  its  surface. 
After  some  experience  one  can  detect  delicate  transverse  lines  or 
waves  passing  upward  and  downward  with  respiration.  These  lines 
correspond  to  the  curvatures  of  the  stomach. 

]\Iore  recently  he  places  the  patient  facing  a  good  light,  and, 
standing  slightly  to  the  side,  observes  the  movements  of  the  trans- 
verse lines.  I  have  seen  good  results  from  this  method,  especially 
for  determination  of  the  lower  border  of  the  stomach. 

The  following  signs  I  have  found  quite  reliable:  With  the 
patient  in  the  recumbent  position,  a  marked  concavity  between  the 
costal  arches — extending  from  the  ensiform  process  to  or  below  the 
umbilicus,  with  a  vertical  median  sulcus,  wider  above  than  below, 
the  abdomen  being  flattened  in  the  central  part  and  bulging  in  the 
lateral  regions — is  significant  of  gastroptosis.  In  the  erect  position 
the  epigastrium  becomes  still  more  depressed,  while  the  umbilical 
and  especiallv  the  pubic  regions  bulge  outvv-ard.  Tumors  of  the 
stomach  may  sometimes  be  obser\'ed,  causing  slight  projection  or 
protuberance  on  the  abdominal  wall. 

Palpation  of  the  Stomach. — Inspection  should  be  supplemented 
by  palpation.  Palpation  should  be  performed  gently  and  the  hands 
of  the  operator  should  be  warm. 

The  patient  should  be  in  the  dorsal  position  with  the  legs  flexed, 
to  relax  the  abdominal  muscles.  He  should  breathe  naturally  and 
keep  the  mouth  open  to  aid  relaxation.  The  physician  should  be 
seated  on  the  right  side  of  the  bed  and  palpate  with  the  right  hand, 
which  should  be  flat  or  slightly  bent  upon  the  abdomen,  with  the 
ulnar  side  down.  One  can  stroke  from  above  downward,  and  with 
practice  it  is  possible,  in  some  cases,  to  feel  the  stomach-wall  and 
appreciate  the  position  of  the  greater  curvature,  as  the  stomach 
gives  a  more  uniform  elastic  sensation  than  do  the  intestinal  walls. 
Some  commence  palpation  from  below  and  work  upward,  dipping 
in  the  ulnar  edge  of  the  hand  rather  deeply.  By  these  means  it 
is  at  times  possible  to  determine  the  position  of  the  greater  cur- 
vature. 

By  palpation  we  can  discover  if  nephroptosis  is  present.  Dias- 
tasis of  the  recti  muscles  and  floating  tenth  rib  can  also  be  deter- 
mined These  conditions  are  significant  of  gastroptosis.  Under 
"Inspection"  I  have  noted  the  signs  that  are  significant  of  gas- 
troptosis. If  we  find  a  "movable  kidney,  "  this  renders  our  diagnosis 
conclusive. 

By  gentle  palpation  one  can  frequently  discover  a  tumor,  its 
position,  size,  consistency,  and  mobility.  Occasionally,  more  pres- 
sure is  necessary  and  the  palpating  hand  may  be  reinforced  by  the 
other  hand,  after  the  method  described. 

Sensitive  or  tender  points  can   be   located    by    palpation;    for 


74  DISEASES    OF   THE   STOMACH   AND   INTESTINES 

example,  the  circumscribed  tenderness  of  an  ulcer  or  the  diffuse 
tenderness  of  the  gastric  region  in  acute  inflammation.  Boas  has 
devised  an  algesimeter  for  indicating  the  degree  of  pain.  T.  Kilmer 
has  also  an  instrument  for  the  same  purpose. 

Considerable  care  should  be  exercised  in  palpation  in  cases  of 
suspected  ulcer,  and  I  prefer  the  hand  for  this  purpose. 

Percussion  of  the  Stomach. — The  accurate  determination  of 
the  position  and  size  of  the  stomach  is  often  difficult  by  simple 
percussion.  The  sound  varies,  according  to  whether  the  organ  is 
empty  or  filled  with  air,  food,  and  water. 

The  position  of  the  patient,  whether  lying  dow^n,  semi-oblique, 
or  standing,  modifies  the  findings.  In  order  to  obtain  results  the 
stomach  should  contain  some  air.  Dehio  has  demonstrated,  both 
on  living  subjects  and  on  the  cadaver,  that  if  the  stomach  is  empty 
the  tympanitic  sound  which  we  produce  on  percussion  is  due  to  the 
colon  and  not  to  the  stomach,  since  the  latter  is  contracted  into  the 
left  concavity  of  the  diaphragm  and  is  not  in  contact  with  the  anterior 
thoracic  wall.  Hence  the  time  at  which  the  examination  is  made 
is  important.  Moreover,  the  lower  curvature  tends  to  fall  awa}^  from 
the  abdominal  wall. 

The  patient  should  first  be  examined  in  the  dorsal  position  with 
the  knees  flexed. 

This  method  determines  wdth  fair  accuracy  the  upper  right  and 
upper  left  portions.  The  percussion  hammer  is  sometimes  an  aid. 
The  absolute  determination  of  the  lower  border  by  percussion  is 
more  difficult.  It  is  rendered  easier  if  the  bowels  have  been  thor- 
oughly emptied,  since  the  colon  is  then  less  likely  to  ride  over  the 
greater  curvature.  The  percussion  sound  over  the  colon  is  lighter 
and  does  not  equal  that  over  the  stomach.  The  stomach  sound  is 
of  greater  intensity  and  clearness  and  of  higher  pitch.  This,  of 
course,  refers  to  conditions  when  air  is  present  as  the  factor.  Food 
or  fecal  contents  alter  the  result,  w^hich  is  further  modified  by  per- 
cussion in  the  semi-oblique  and  standing  positions. 

As  a  rule,  there  are  some  contents  in  the  transverse  colon,  so  that 
we  have  the  tympanites  of  the  stomach  merging  into  dulness  or 
flatness.  With  gastroptosis,  determination  of  the  position  of  the 
organ  b}^  simple  percussion  is  often  difficult. 

The  presence  of  a  tumor  can  frequently  be  determined  by  percus- 
sion. 

Auscultatory  Percussion. — With  this  method  we  employ  the 
stethoscope.  The  chest-piece  may  be  placed  above  the  seventh  rib 
in  the  left  mammillary  line,  or  between  the  tip  of  the  ensiform  process 
and  the  left  costal  margin;  or  in  the  same  vertical  line,  but  slightly 
below  these  points.  First  percuss  near  the  stethescope  to  fix  the 
characteristic  sound.  The  tympanites  of  the  stomach  is  transmitted 
generally  through  the  liver  and  lung.  The  percussion  should  be 
begun  well  distant  from  the  possible  location  of  the  stomach,  and 


METHODS    OF    PHYSICAL    EXAMINATION    OF   THE    STOMACH 


75 


should  be  performed  in  the  vertical  direction,  downward  and  upward, 
and  also  laterally.  One  should  begin  nearly  at  the  symphysis  and 
percuss  in  vertical  lines  upward  (Fig.  37). 


Fig-  37- — Vertical  lines  of  auscultatory  percussion.     Circles  show  positions  of 

stethoscope. 

The  patient  should  be  in  the  usual  position,  as  described,  and 
should  hold  the  stethoscope  for  the  operator  against  the  abdomen. 


Fig.  38. — Auscultatory  percussion  of  tumor  of  stomach  wall. 

A  sound  of  greater  intensity  and  clearness  and  of  higher  pitch  denotes 
the  border  of  the  stomach.     The  greater  bulk  of  the  organ,  when 


76  DISEASES    OF   THE    STOMACH    AND    INTESTINES 

dilated  or  in  a  condition  of  ptosis,  lies  to  the  left  of  the  median  line. 
We  must  remember  that  some  cases  of  marked  dilatation  extend  a 
great  distance  to  the  right  of  the  abdomen. 

This  method  is  of  value  in  determination  of  a  tumor  of  the 
stomach. 

Place  the  stethoscope  at  O,  Fig.  38,  and  percuss  toward  the  tumor 
from  all  directions.  The  sound  heard  over  the  tumor  (C)  differs  in 
character  from  that  heard  over  the  stomach  at  D.  If  the  growth 
involves  the  stomach  wall,  C  resembles  D  much  more  nearly  than 
A  (percussion  of  liver)  and  B  (percussion  of  intestine)  resembles  D 
(stomach  percussion). 

Differential  Diagnosis. — If  a  tumor  Hes  at  D,  near  the  margin 
of  the  liver  (Fig.  39),  tumor  of  the  liver  is  excluded  as  follows:  place 
stethoscope  at  S,  over  liver.     Percussion  note  over  D  resembles  note 


Fig.  39. — Differential  diagnosis. 

over  G  more  than  it  resembles  that  over  F.  Then  to  exclude  intestines, 
shift  stethoscope  to  K,  over  stomach.  Percussion  over  D  resembles 
that  over  M  more  closely  than  that  over  G  resembles  that  over  M. 
The  tumor  is,  therefore,  of  the  stomach. 

Reichmann's  Rod. — This  consists  of  a  short  ivory  rod,  with 
circular  grooves  and  intervening  projections,  like  the  handle  of  an 
ivory  knitting-needle.  The  rod  is  pushed  firmly  down  over  the 
stomach  at  a  right  angle  to  its  surface  (in  a  vertical  line  to  the 
abdomen),  and  is  gently  stroked  with  the  fmger.  The  stethoscope 
is  applied  over  the  organ  and  the  "pitch  "  carefully  observed.  When 
the  rod  passes  beyond  the  limits  of  the  stomach,  a  change  in  "pitch" 
occurs. 

Scratch  Method  of  Auscultatory  Percussion. — This  method 
I  have  found  satisfactorv  in  manv  cases. 


METHODS    OF    PHYSICAL    EXAMIXATION    OF    THE    STOMACH  77 

The  stethoscope  is  placed  on  the  abdomen  below  the  left  border 
of  the  ribs,  and  with  the  index-finger  of  the  right  hand  the  abdominal 
wall  is  scratched  gently  by  the  examiner  so  as  to  secure  the  "normal 
pitch"  over  the  stomach.  The  abdomen  is  then  scratched  lightly 
from  below  upward,  commencing  below  the  umbilicus,  and  the 
change  in  "pitch"  is  readily  observed  when  the  lower  border  of  the 
stomach  is  reached. 

If  gastroptosis  is  believed  to  exist,  the  stethoscope  is  placed  more 
to  the  left,  and  the  "scratch  pitch"  noted  from  left  to  right.  The 
method  is  shown  in  Fig.  40.  It  is  of  special  value  in  determining 
the  lower  border  of  the  stomach. 


Fig.  40. — "Scratch  method"  of  auscultatory  percussion. 

Flicking. — This  method  was  described  and  illustrated  in  the 
previous  chapter. 

Inflation  of  the  Stomach  with  Carbonic  Acid  Gas. — Carbonic 
acid  gas  inflation  is  employed  to  render  the  stomach  visible  to 
inspection;  to  aid  the  determination  of  the  position  of  the  lesser 
curA^ature.  as  well  as  the  greater,  and  so  enable  a  differential  diagnosis 
between  dilatation  and  gastroptosis. 

The  method  is  to  administer,  first,  one-half  glass  of  water  in 
which  about  i  dram  of  tartaric  acid  is  dissolved  and,  after  this 
one-half  glass  of  water  containing  from  i  to  i^  drams  of  soda  bi- 
carbonate. If  small  quantities  are  employed  the  stomach  will  not 
become  visible  and  palpable. 


78  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

There  are  certain  objections  to  this  procedure.  At  times  there 
is  considerable  escape  of  gas  through  the  cardiac  orifice  or  pylorus 
and  the  small  intestine  may  be  distended.  This  is  a  possible  source  of 
error.  There  may  be  sudden  hyperdistention  of  the  stomach,  with 
resulting  pressure  on  the  heart  and  lungs,  and  unpleasant  or  even 
dangerous  symptoms  result  in  the  aged  or  in  a  patient  suffering  from 
cardiac  or  pulmonary  disease.  In  the  chapter  on  xVcute  Dilatation 
of  the  Stomach  the  effects  of  sudden  distention  of  the  stomach  on 
the  heart  and  circulation  are  described  by  Thomas  Satterthwaite 
and  the  author. 

When  there  has  been  a  hemorrhage,  or  symptom^s  of  ulcer  or 
cancer,  or  signs  of  peritonitis,  the  use  of  this  method  is  contra- 
indicated.  Several  fatal  accidents  have  occurred.  It  sometimes 
irritates  the  mucous  membrane.  One  could  employ  a  stomach-tube 
and  Dr.  Rose's  carbonic  acid  gas  generating-bottle  as  a  substitute. 
Carbonic  acid  gas  inflation  is  valuable  in  those  who  are  in  fair 
physical  condition. 

In  the  determination  of  the  position  of  a  tumor,  whether  it  hes 
on  the  anterior  or  posterior  surface  of  the  stomach,  it  is  of  service. 
A  posterior  tumor  will  disappear  under  inflation.  This  is  fully 
described  under  Cancer  of  the  Stomach. 

Inflation  of  the  Stomach  with  Air. — This  consists  in  introducing 
a  soft  stomach-tube  and  slowly  pumping  air  into  the  stomach  with 
a  double-bulb  or  a  Davidson's  syringe.  The  tube  should  be  intro- 
duced with  the  patient  sitting  up  in  bed,  and  he  should  then  gently 
recline  on  the  back,  and  inflation  should  be  carried  out.  It  possesses 
the  advantage  that  the  amount  of  air  pumped  into  the  stomach  can 
definitely  be  regulated.  Fill  a  vessel  with  i  liter  ( i  quart)  of  water, 
invert  it  over  a  pail  of  w^ater,  and  note  how  many  compressions  of 
the  bulb  displace  the  given  quantity  of  fluid.  One  can  thus  estimate 
the  quantity  of  air  pumped  in  at  each  compression.  The  first  few 
squeezes  of  the  bulb  should  be  given  rapidly,  so  as  to  cause  spasmodic 
closure  of  the  pylorus. 

The  same  indications  and  contra-indications  exist  as  for  the  use 
of  carbonic  acid  gas.  There  is  the  advantage  of  being  able  to 
regulate  more  definitely  the  degree  of  inflation.  Some  patients, 
however,  object  to  the  passage  of  the  tube.  If  there  are  discomfort 
or  unpleasant  symptoms  from  either  method  of  inflation,  the  con- 
dition should  be  immediately  relieved  by  the  passage  of  the  stomach- 
tube. 

Fiirbringer  suggests  that  when  we  inflate  with  air  the  tube  should 
be  introduced  only  to  the  middle  of  the  esophagus,  and  air  should 
then  be  pumped  in.     He -claims  that  this  procedure  prevents  retching. 

Inflation  of  the  Stomach  with  Water. — To  Dehio  we  must  give 
the  credit  of  determining  the  position  of  the  stomach  by  water 
inflation.  He  percusses  over  the  patient's  stomach,  preferably  w4th 
the  organ  empty  and  the  patient  in  the  erect  position.      He  then 


METHODS    OF    PHYSICAL    EXAMINATION    OF   THE    STOMACH  79 

administers  a  glass  of  water  (8  ounces),  not  too  cold,  and  percusses 
the  area  of  dulness.  He  follows  this  with  a  second,  third,  and 
fourth  glass  of  water,  percussing  each  time,  and  notes  the  position 
and  extent  of  the  dulness.  The  patient  is  then  directed  to  lie  on 
his  back  and  tympanites  will  appear  where  dulness  previously 
existed.  This  conclusively  demonstrates  that  the  area  corresponded 
to  the  stomach. 

If  there  is  pronounced  dilatation  or  ptosis,  a  single  glass  of  water 
will  often  cause  dulness  to  appear  below  the  navel  or  in  the  inguinal 
region.  The  results  may  be  obscured  in  patients  with  much  adipose 
tissue  or  if  there  is  fecal  accumulation  in  the  colon.  In  this  event, 
it  should  be  cleared  out  by  injection.  I  have  also  found  the  following 
method  of  value,  especially  if  there  be  some  gastric  contents:  first, 
place  the  patient  in  the  semi-oblique  position  and  percuss  the  stomach ; 
then  administer  2  or  even  3  glasses  of  water.  We  secure  stomach 
tympanites  above,  then  a  band  of  stomach  dulness  and  intestinal 
tympanites  below.  It  is  easier  to  differentiate  between  dulness  and 
tympanites  than  between  two  types  of  tympanites. 


Fig.  41. — Kemp's  stomach-whistle. 

There  are  numerous  complicated  methods  by  means  of  inflatable 
bags,  manometers,  etc.,  for  determining  the  position  of  the  stomach, 
which  are  scarcely  of  practical  value.  Leube  introduces  a  stiff 
sound  and  determines  the  position  of  its  lower  end  through  the 
abdominal  walls.  This  method  does  not  seem  to  be  safe.  Others 
differentiate  between  the  stomach  and  the  colon  by  inflating  the 
colon  with  air  or  carbonic  acid,  employing  the  same  methods  as  in 
the  stomach,  only  using  twice  the  quantity  of  soda  bicarbonate  and 
tartaric  acid.  Rose's  apparatus  would  prove  of  value  to  inflate 
the  bowel.  To  further  differentiate,  water  was  given  by  the  stomach. 
Some  first  empty  the  bowel  thoroughly  and  then  inflate  the  intestine 
with  water.     It  is  often  difficult  for  the  patient  to  hold  the  enema. 

There  are  two  other  methods  for  determining  the  lower  margin 
of  the  stomach:  First,  the  administration  of  small  quantities  of 
soda  bicarbonate  and  tartaric  acid,  with  the  patient  in  the  standing 
position.  In  some  cases  one  can  approximately  map  out  the  lower 
borde-  of  the  stomach  by  listening  to  the  "sizzling  sounds"  with 
the  stethoscope.  Second,  the  use  of  the  stomach-whistle  (Fig.  41). 
This  consists  of  a  rectal  tube  of  small  caliber,  with  a  whistle  in  the 


8o  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

end.  To  the  other  extremity  is  attached  an  ordinary  stomach 
aspirating  bulb  without  valves.  The  tube  is  inserted  into  the 
stomach,  the  finger  placed  over  the  open  end  of  the  bulb,  and  a  single 
bulbful  of  air  is  forced  into  and  aspirated  out  of  the  stomach  by  rapid 
and  short  intermittent  contractions.  This  entirely  eliminates  the 
possible  chance  of  distending  the  stomach  with  air  and  the  organ 
remains  practically  empty. 

A  stethoscope  is  placed  over  the  abdomen  and  the  point  of 
greatest  intensity  of  sound  is  marked  by  a  cross  with  a  colored  pencil. 
The  tube  is  pushed  in  and  out  and  the  various  points  of  sound  are 
marked — the  lowest  is  in  the  lower  border  of  the  stomach.  The  ear 
can  be  applied  in  place  of  the  stethoscope.  Transillumination  of  the 
organ  was  then  performed  and  the  lower  margins  absolutely  corres- 
ponded. The  method  of  administering  water  and  then  blowing 
air  into  the  stomach  through  a  tube,  and  producing  "bubbling 
sounds,"  only  gives  the  level  of  the  fluid,  and  not  accurately  the 
lower  margin  of  the  stomach.  The  whistle  will  not  differentiate 
between  dilatation  and  gastroptosis.  This  experiment  with  the 
stomach-whistle  demonstrated  that  in  the  standing  position  the 
stomach,  when  empty,  descends  to  the  full  length  of  its  suspensory 
ligaments,  and  its  lower  border  is  at  a  constant  level  or  within  about 
I  inch  of  the  same,  whether  the  organ  be  full  or  empty.  It  was  at 
the  same  level  when  a  pint  or  more  of  fluorescent  fluid  had  been 
ingested, as  when  demonstrated  by  transillumination. 

Splashing  Sounds. — The  splashing  sounds  of  the  stomach  are 
produced  when  water  and  air  in  the  organ  are  agitated  together, 
when  either  the  whole  body  or  the  stomach  alone,  is  shaken.  They 
are  best  demonstrated  by  rapidly  tapping  with  the  index-  and  middle 
fingers  of  the  right  hand  over  the  stomach  several  times  in  succession 
without  removing  the  fingers,  as  in  striking  chords  on  the  piano. 
The  patient  should  be  in  the  dorsal  position  with  the  lower  limbs 
flexed. 

The  sounds  resemble  those  produced  by  shaking  a  rubber  bag 
containing  air  and  water. 

They  can  be  elicited  in  many  people  in  ordinary  good  health 
shortly  after  meals,  but  if  found  at  an  abnormal  time  or  in  an  abnor- 
mal position,  are  of  diagnostic  value.  If  present  an  hour  after  a 
test  breakfast,  the  patient  suffering  from  gastric  symptoms  and  the 
position  of  the  stomach  being  normal,  they  are  significant  of  simple 
atony.  This  is  true  if  they  be  found  several  hours  after  an  ordinary 
meal  or  on  an  empty  stomach.  If  the  splash  is  present  in  an  abnormal 
position  at  the  level  or  below  the  umbilicus,  it  shows  the  lower  border 
of  the  stomach  lies  abnormally  low,  and  that  either  dilatation  or 
gastroptosis  is  present. 

The  presence  of  movable  kidney  demonstrates  it  is  a  ptosis. 
The  upper  border  may  be  determined  to  be  in  an  abnormal  position 
by  inflation  or  gastrodiaphany,  as  a  further  test. 


METHODS    OF    PHYSICAL   EXAMINATION    OF    THE    STOMACH 


The  splashing  sound  determines  the  position  of  the  lower  border 
of  the  stomach  with  greater  accuracy  than  percussion.  Some 
patients  hold  the  abdomen  rigid,  so  that  it  does  not  appear  on  exami- 
nation, but  it  can  be  produced  artificially  for  examination  purposes. 

The  following  is  a  simple  method  to  differentiate  between  stomach 
and  intestinal  splash: 

In  Fig.  42,  if  the  splash  be  found  at  A,  mark  same  on  abdominal 
wall ;  then  give  several  glasses  of  water  or,  preferably,  Vichy.  If  the 
splash  at  A  be  intensified,  it  is  stomach  splash.  If,  on  the  other 
hand,  the  splash  appear  at  B,  this  is  the  true  stomach  splash  and 
.4  is  the  intestinal  splash. 

If  no  splash  is  present  on  examination, 
it  can  be  created  artificially  by  giving 
several  glasses  of  water  or,  preferably,  Vichy. 
Sometimes  3  or  4  glasses  are  required;  the 
patient  takes  several  deep  breaths,  the 
splash  being  determined  during  expiration. 
I  find  the  determination  of  the  lower  border 
of  the  stomach  most  accurate  by  means  of 
the  splashing  sound. 

Deglutition  Sounds. — These  were  first 
described  by  Kronicker  and  Meltzer.^ 

When  drinking,  a  sound  is  heard  simul- 
taneously with  the  act  of  deglutition,  which 
is  termed  the  first  deglutition  sound.  A 
second  sound  is  noted  about  seven  seconds 
later.  Both  sounds  can  be  heard  by  placing 
the  ear  or  stethoscope  at  theensiform  process. 
As  a  rule,  only  the  second  sound  is  heard.  If  the  first  sound  is  heard, 
the  second  may  be  present  or  absent.  The  presence  of  these  sounds 
assists  in  forming  judgment  as  to  the  permeability  of  the  cardiac 
orifice.  If  they  are  absent,  the  ingested  liquid  has  remained  in  the 
esophagus,  and  hence  a  tight  stricture  is  present.  If  the  second 
sound  is  markedly  delayed,  there  is  probably  partial  obstruction. 

Other  Sounds  Have  Been  Described. — Dripping  sounds, 
arising  from  the  passage  of  fluid  along  the  gastric  wall,  are  sug- 
gested as  a  means  of  mapping  out  the  stomach.  The  method  is 
inaccurate. 

The  succussion  sound,  obtained  by  shaking  the  body  of  the 
patient,  is  not  as  accurate  a  method  as  by  tapping. 

Gurgling  sounds  occur  from  the  contraction  of  the  empty  stomach 
about  air  or  gas.  Sounds  are  heard  in  the  stomach  due  to  movements 
imparted  to  the  organ  through  the  respiration,  and  also  ringing 
sounds,  imparted  from  the  heart  in  gastric  dilatation.^ 

These  sounds  are  of  no  diagnostic  value.     Occasionally  sizzling 

^Centralb.  f.  die  med.  Wissensch.,  1883,  No.  i. 

2  Laker,  Wiener  med.  Presse,  1889,  Nos.  43  and  44. 


Fig.  42. — Splashing 
sound.  Differential  diag- 
nosis between  stomach 
and  intestinal  splash. 


82  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

sounds  are  heard  on  auscultation,  which  are  produced  by  fermentation 
of  the  gastric  contents.  They  resemble  the  sounds  produced  after 
the  administration  of  soda  bicarbonate  and  tartaric  acid,  with  the 
resulting  generation  of  carbonic  acid  gas. 

Esophagoscopy. — Mikulicz,  Rosenheim,  Kelling,  Von  Hacker,^ 
Einhorn,"  and  many  others  have  advocated  this  method. 

In  the  earlier  instruments  the  source  of  illumination  was  outside 
the  esophageal  tube.  The  instrument  with  the  lamp  at  the  end  of 
the  tube  near  the  point  to  be  inspected,  such  as  devised  by  Einhorn, 
is  more  practical. 

In  Fig.  43  is  depicted  Einhorn's  instrument,  w^hich  is  readily 
understood. 

The  obturator  is  inserted  and  held  in  place  by  the  plug  d  and  the 
wires  connected  with  the  battery. 

After  introduction,  the  plug  is  removed,  the  obturator  with- 
drawn, and  the  current  turned  on. 


Fig.  43. — Einhorn's  esophagoscope. 

Technic. — The  pharynx  should  be  sprayed  with  cocain  (5  per 
cent.).  The  patient  sits  on  a  chair  with  a  straight  back.  The 
instrument  with  obturator  inserted  is  immersed  in  warm  water  and 
inserted  like  a  pen  along  the  roof  of  the  mouth  to  the  posterior  wall 
of  the  pharynx,  the  head  being  thrown  backward  on  the  shoulders. 
It  is  then  pushed  down  in  a  vertical  line  into  the  esophagus  without 
the  exertion  of  any  force.  By  this  method  it  is  unnecessary  to  press 
down  on  the  tongue,  and  thus  gagging  is  avoided. 

The  lips  of  the  patient  should  not  be  pressed  upon  by  the  instru- 
ment. The  obturator  is  removed,  the  light  turned  on,  and  the  eye 
of  the  operator  applied  to  the  opening. 

For  complete  inspection  of  the  esophagus,  the  instrument  is 
gradually  withdrawn. 

This  esophagoscope  is  made  in  several  lengths  and  in  two  sizes. 

*  Beitrage  zur  klinischen  Chirur.,  Bd.  20,  1898,  pp.  141,  275;  Ibid.,  Bd.  29, 
1901,  p.  128. 

2  New  York  Med.  Journal,  Dec.  11,  1897. 


METHODS    OF    PHYSICAL   EXAMINATION    OF   THE    STOMACH  83 

Indications. — Esophagoscopy  is  of  chief  value  for  the  removal 
of  foreign  bodies.  It  may  be  employed  in  cases  of  suspected  ulcera- 
tion and  for  topical  application  thereto.  In  suspected  cancer  it 
should  be  used  with  caution. 

Conira-indications. — Aneurism  or  recent  hemorrhage. 

Gastroscopy. — This  method  of  examination  of  the  gastric  mucosa 
was  inaugurated  by  ^Mikulicz  in   1881.^ 

The  general  principle  of  the  instrument  is  based  on  the  cystoscope. 
Rosenheim  has  devised  a  new  instrument,  and  Chevalier  Jackson 
has  carried  on  numerous  investigations  in  gastroscopy.  The  latter 
has  conclusively  demonstrated  that  general  anesthesia  should  be 
given  for  such  an  examination. 

I  must  confess  that  in  cases  of  suspected  cancer  or  ulcer  I  would 
not  submit  a  patient  to  the  certain  degree  of  risk  from  the  introduc- 
tion of  an  instrument  of  the  present  type;  and  in  milder  cases  of 
gastric  disturbances  I  can  see  no  advantage,  except  for  the  purpose 
of  scientific  study.  It  would  seem  that  a  large  number  of  normal 
organs,  as  well  as  mild  types  of  gastric  disease,  should  first  be  investi- 
gated as  a  basis  for  comparison,  and  that  the  instrument  should  be 
improved  upon  before  the  method  can  be  generally  recommended. 

Gastrodiaphany  or  Transillumination  of  the  Stomach. — 
Casenave,  in  1845,  first  applied  the  method  of  transillumination  to 
living  tissues.  In  1867  Milliot  succeeded  in  transilluminating  the 
stomachs  of  animals  and  experimented  with  the  stomachs  of  cadavers, 
but  to  Max  Einhorn,  of  New  York,  the  credit  is  due  of  being  the  first 
to  demonstrate  transillumination  of  the  stomach  on  the  living  subject 
and  the  practical  value  of  gastrodiaphany.  His  instrument,  which 
he  denominates  a  gastrodiaphane,  consists  of  a  soft-rubber  stomach- 
tube,  at  one  end  of  which  is  fastened  an  Edison  lamp.  Conducting 
wires  run  through  the  tube  to  the  battery,  and  there  is  a  current 
interrupter  at  some  distance  from  the  tube.  The  lamp  is  enclosed 
in  a  glass  bulb,  to  act  as  a  reflector  and  prevent  the  action  of  heat  on 
the  stomach.  He  has  the  patient  drink  only  i  or  2  glasses  of  water, 
so  as  not  to  distend  the  stomach,  inserts  the  light,  and  examines  the 
case  in  a  dark  room,  either  in  the  sitting  or  in  the  recumbent  position. 

Heryhg  and  Reichmann  employ  a  modified  tube,  with  a  water 
cooler  about  the  lamp.  Kutner  and  Jacobson,  under  Ewald's  direc- 
tion, performed  a  great  number  of  experiments. 

These  experimenters,  together  with  Meltzing,  are  the  chief 
foreign  investigators  with  gastrodiaphany.  Manges,  Stockton,  and 
many  others  have  employed  it.  Among  various  gastrodiaphanes 
are  those  of  Hemmeter,  Lincoln,  Solis-Cohen,  Koplik,  and  Lock  wood. 
To  Lockwood  we  must  credit  a  decided  advance  in  the  type  of 
instrument — a  fine,  wire-bound  cable  (rubber  insulated)  and  a  small 
Ught,  no  larger  than  a  5-grain  capsule.  The  cut  of  my  instrument, 
the  "circumscribing  gastrodiaphane,"  will  sufficiently  explain  the 
^Wiener  med.  Presse,  1881,  No.  45. 


84  DISEASES   OF   THE    STOMACH   AND    INTESTINES 

Lock  wood  instrument,  after  which  it  is  modeled,  with  certain 
additions. 

The  Circumscribing  Gastrodiaphane. — A  series  of  observations 
with  transillumination  of  the  stomach  suggested  an  improvement 
on  the  gastrodiaphanes  in  use.  Manipulation  of  the  tube  after  the 
electric  light  has  entered  the  stomach  frequently  causes  gagging  and, 
at  times,  vomiting,  interfering  thus  with  the  accuracy  of  the  method. 
The  cables  of  all  the  instruments  were  found  unsatisfactory  in  cases 
of  gastroptosis  of  great  degree  when  we  endeavored  to  explore  care- 
fully the  pyloric  end  of  the  greatly  dilated  stomach.  It  was  impossi- 
ble to  guide  the  light  in  a  definite  direction ;  it  would  sometimes  pass 
to  the  right,  sometimes  to  the  left,  and  often  it  was  necessary  to  draw 
it  in  and  out  a  number  of  times  for  a  distance  of  several  inches. 

The  instrument  I  devised  to  overcome  these  drawbacks  has  a 
cable  about  6  inches  longer  than  the  Lockwood  gastrodiaphane,  and 


Fig.  44. — Kemp's  gastrodiaphane  (circumscribing). 

is  of  about  the  same  caHber  (Fig.  44).  The  cable  is  more  flexible 
for  the  space  of  I  inch  at  about  the  same  distance  from  the  light — 
in  effect,  a  joint  at  this  point.  At  the  base  of  the  light  is  attached 
an  extremely  thin  accessory  cable,  covered  with  rubber.  This  runs 
parallel  with  the  main  cable  and  increases  the  diameter  only  a  very 
slight  degree.  After  introduction  of  the  instrument  the  main  cable 
is  held  firmly  and  the  accessory  cable  drawn  upon.  By  turning  the 
cable  at  the  same  time,  the  instrument  can  be  directed  in  the  desired 
direction.  By  manipulation  of  the  accessory  cable  the  main  cable 
can  be  so  bent  that  the  light  will  explore  the  entire  wall  of  the 
stomach  anteriorly,  and  can  be  made  to  pass  up  to  the  pylorus  and 
along  the  borders  of  the  ribs.  The  lesser  curvature  is  thus  explored. 
Care  should  be  taken  that  the  cables,  are  parallel  when  passed 
into  the  stomach,  and  the  accessory  cable  should  be  relaxed  before 
withdrawal.     The  main  cable,  except  at  the  joint  near  the  light, 


METHODS    OF    PHYSICAL    EXAMINATION    OF   THE    STOMACH  85 

is  stiffer  than  the  Lockwood  Hght.  Eight  dry  cells  are  employed 
with  a  rheostat.  Wappler  manufactures  a  small  pocket  battery 
with  six  cells,  which  I  have  found  excellent.  An  extra  lamp  should 
be  carried.     Water  was  the  medium  formerly  employed. 

A  great  advance  in  the  technic  of  gastrodiaphany  is  the  employ- 
ment of  fluorescent  media. ^ 

There  are  three  such  media  found  to  be  of  value: 

Bisulphate  of  quinin,  gr.  10  (0.6),  in  a  pint  of  water.  The  addition 
of  Tn.5  (0.3)  of  dilute  phosphoric  acid  intensifies  its  action.  The 
same  amount  of  dilute  sulphuric  acid  may  be  substituted.  The 
reaction  of  the  quinin  solution  is  acid  and  the  fluorescence  a  very 
pale  violet.  Increased  acidity  intensifies  its  action  and  fluorescence 
disappears  if  the  solution  is  rendered  alkaline. 

Esculin.  This  is  derived  from  the  CEsculus  hippocastanum 
(horse-chestnut),  indigenous  to  Europe;  15-gTain  doses  have  been 
used  in  malaria.  One  can  employ  small  doses,  gr.  -§-  to  |  (0.008- 
0.032),  in  a  pint  of  alkaline  solution,  which  gives  a  blue  fluorescence. 
This  preparation  is  difficult  to  secure  and  is  expensive. 

Fluorescein  (phthalic  anhydrid,  5  parts),  a  naphthalin  product, 
and  resorcin  (7  parts),  heated  to  200  C.  (392  F.).  It  is  a  reddish 
powder,  faintly  soluble  in  water,  with  a  neutral  action,  and  gives 
thus  no  fluorescence;  soluble  in  alcohol  and  in  alkaline  media,  it 
gives  a  green  fluorescence  like  liquid  opal.  It  has  been  employed 
to  detect  ulcers  of  the  cornea.  It  can  be  secured  from  Merck  &  Co., 
and  is  extremely  cheap. 

The  addition  of  glycerin  intensifies  the  fluorescence,  and  the 
hydrochloric  acid  of  the  stomach  must  first  be  neutralized.  The 
patient  should  first  be  given  a  glass  of  water  (8  oz. — 250  cc.)  in 
which  gr.  15  (i.o)  of  bicarbonate  of  soda  have  been  dissolved. 
A  second  glass  of  water  (8  oz. — 250  cc.)  is  then  administered,  in 
which  are  dissolved  the  same  amount  of  sodium  bicarbonate,  i  dram 
(4.0)  of  glycerin,  and  gr.  i  to  |  (0.008-0.016)  of  fluorescein;  i  or  2 
ounces  of  lime-water  may  be  substituted  for  the  sodium  bicarbonate. 

As  we  increase  the  fluorescein  in  strength,  fluorescence  diminishes 
and  colorization  begins.  By  means  of  fluorescent  media  I  have 
found  it  -possible  to  illuminate  the  stomachs  of  fat  or  muscular 
subjects  that  were  formerly  unsatisfactory,  and  to  examine  for 
tumors  and  the  location  of  the  stomach  with  greater  accuracy. 
The  brilliancy  of  the  illumination  is  markedly  increased. 

Examination  of  the  urine  of  patients  Avho  have  taken  fluorescein 
shows  no  deleterious  effects — no  albumin,  no  sugar,  no  casts.  The 
fluorescein  acts  in  an  alkaline  medium  and  free  acid  destroys  fluores- 
cence, yet  on  catheterization  of  these  patients  greenish  fluorescent 
urine  is  obtained  one  hour  after  the  administration  of  fluorescein 
solution,   and   this   condition   persists   for   about   four  hours.     The 

1  New  York  Med.  Journal;  Philadelphia  Med.  Journal,  Feb.  13,  1904;  New 
York  Med.  Journal,  August  6,  1904. 


86 


DISEASES   OF  THE   STOMACH  AND   INTESTINES 


acidity  of  the  urine  is  not  due  to  the  presence  of  free  acid.  In 
fluorescein  solution  we  have  an  additional  means  of  testing  the 
permeability  of  the  kidneys. 

The  technic  of  gastrodiaphany  is  as  follows:  The  patient's 
stomach  should  be  empty.  He  is  given  a  glass  (8  oz.— 250  cc.)  of 
the  alkaUne  solution,  and  then  a  second  glass  (8  oz. — 250  cc.)  of  the 
fluorescein  solution.  I  frequently  give  an  extra  half  or  even  two 
additional  glasses  of  water,  especially  in  the  suspected  cases  of  dilata- 
tion or  ptosis,  or  in  stout  subjects.  In  the  latter,  gastrodiaphany 
is  not  as  satisfactory,  but  by  pressing  on  the  abdominal  wall  the 
outlines  can  be  secured.  ■ 


-pig  45. — Gastrodiaphany:  A,  Normal  stomach;  B,  dilated  stomach;  C,  D,  E,  F, 
varying  degrees  of  gastroptosis  (Rose  and  Kemp). 

A  dark  room  gives  the  only  satisfactory  results.  It  can  be 
devised  by  pinning  blankets  across  the  windows.  The  patient  can 
also  be  examined  in  a  light  room  by  covering  him  from  neck  to  feet 
with  a  dark  blanket  or  black  gown,  and  the  examiner  looking  through 
an  opening  therein. 

The  gastrodiaphane  is  introduced  by  gaslight  or  candlelight, 
the  patient  sitting  opposite  in  a  chair,  with  the  abdomen  exposed. 
The  electric  current  is  turned  on  and  the  room  darkened.  The 
patient  should  then  stand  up,  as  this  position  is  preferable.  It  is 
my  custom  to  mark  out  the  anatomic  regions  on  the  abdomen  of 
each  case  with  blue  pencil,  and  then  draw  the  outlines  of  the  stomach 
during  transillumination. 

With  gastroptosis,  the  lesser  curvature  can  be  determined.     In 


METHODS    OF    PHYSICAL   EXAMINATION    OF   THE    STOMACH 


87 


Fig.  46. — Cancer  of 
greater  curvature. 
Gastrodiaphany, 


some  cases  the  stomach  will  be  bottle-neck  above,  with  the  base 
below;  or  somewhat  pear  shaped,  the  narrow  part  showing  above, 
as  the  light  disappears  beneath  the  ribs.  In  a  dilated  stomach  the 
transverse  diameter  of  transillumination  is  nearly  the  same  through- 
out; as  we  withdraw  the  light  it  begins  to  narrow  just  below  the  tip 
of  the  ensiform.  If  we  illuminate  in  the  dorsal  position,  the  light 
hardly  shows  at  all;  it  becomes  clearer  as 
the  patient  gradually  sits  erect,  and  is  most 
marked  in  the  standing  position.  This  sub- 
stantiates the  view  of  Meltzing,  who  states 
that  in  the  dorsal  position  only  a  portion  of 
the  stomach  is  in  contact  with  the  abdominal 
wall,  and  it  demonstrates  the  necessity  of  the 
standing  position  for  accurate  illumination. 

In  Fig.  45  are  shown  a  normal  stomach, 
the  dilated  organ,  and  several  degrees  of 
gastroptosis.  There  is  no  question  but  that 
ptosis  of  the  stomach  exists  from  a  very 
slight  to  an  extreme  degree.  Tumors  or 
thickenings  of  the  anterior  wall  of  the 
stomach,  or  the  lesser  or  greater  curvature, 
or  anterior  surface  of  the  pylorus,  appear 
as  a  dark  area  projecting  into  or  surrounded 
by  a  light  zone   (Fig.  46). 

By  the  circumscribing  gastrodiaphane  the  entire  contour  of  the 
stomach  is  determined.  The  older  instruments  show  only  the  lower 
segment  clearly. 

RONTGEN  RAYS  (X-RAYS) 

The  most  valuable  practical  application  of  the  x-rays^  in  reference 
to  the  stomach  is  for  the  detection  of  a  foreign  body  which  is  believed 
to  be  lodged  within  the  organ  and  for  demonstrating  its  location. 
The  question  often  of  operation  and  the  location  of  the  incision 
depend  upon  the  information  secured  by  this  means. 

Cannon  has  made  a  valuable  study  of  the  motions  of  the  stomach 
with  the  x-rays,  to  which  I  have  alluded. 

Rontgenography  of  the  stomach  has  been  performed  bv  numerous 
observers  for  the  purpose  of  locating  the  position  of  the  organ. 

The  patient  on  an  empty  stomach  is  given  i  pint  of  milk,  in 
which  I  ounce  or  more  of  bismuth  subnitrate  has  been  thoroughly 
mixed.  On  exposure  to  the  x-rays  for  about  fifteen  seconds,  from 
a  photographic  plate  placed  direct!}^  over  the  abdomen,  a  picture 
can  be  obtained ;  or  with  a  fluoroscope  the  stomach  can  be  inspected. 

This  method  is  expensive  for  the  patient,  and  no  information  can 
be  secured  that  cannot  be  obtained  by  the  physical  examination, 
especially  by  transillumination.     The  Rontgen  picture  shows  onl}'' 

'  Their  use  in  carcinoma  of  the  stomach  and  in  stenosis  of  the  esophagus  are 
described  under  these  topics. 


88  DISEASES   OF   THE    STOMACH   AND    INTESTINES 

the  greater  curvature  and  part  of  the  body  of  the  stomach;  the 
lesser  cur\^ature  is  not  dehneated.  This  can  be  demonstrated  by 
comparing  the  result  with  subsequent  gastrodiaphany. 

By  the  administration  of  bismuth  subnitrate  capsules  the  lower 
border  of  the  stomach  can  be  delineated  by  the  a[;-rays. 

RADIUM  TRANSILLUMINATION  OF  THE  STOMACH 

This  method  was  first  suggested  by  Einhorn.^  with  his  radio- 
diaphane  (Fig.  47),  a  rubber-covered  glass  capsule,  containing 
0.05  gm.  bromid  of  radium  (Curie,  1,000,000  strength),  an  inflating 
bulb,  and  Kahlbaum's  fluoroscope.  The  transillumination  is  very 
faint  and  the  results  not  as  clear  as  from  gastrodiaphany.     The 


Fig.  47. — Einhorn's  radiodiaphane. 

expense  is  considerable.     At  the  present  stage  of  its  development 
I  would  not  recommend  it  as  of  practical  value. 

RADIUM  PHOTOGRAPHS  OF  THE  STOMACH 
The  same  may  be  said  of  this  procedure  devised  by  Einhorn.^ 
The  length  of  exposure  to  radium  is  never  less  than  an  hour 

and,  preferably,  longer  to  secure  results. 

This  is  decidedly  objectionable,  as  severe  burns  are  possible  from 

radium.     If  photographs  are  to  be  taken,  the  x-rays  are  safer  and 

give  more  definite  results. 

CONCLUSIONS 

The  following  methods  I  have  found  from  experience  to  be  most 
practical  for  general  use: 

Inspection. — By  this  method  the  peculiar  shape  of  the  abdomen, 
suggestive  of  gastroptosis,  can  at  once  be  determined. 

Palpation. — If  movable  kidney  be  present,  it  is  pathognomonic 
of  gastroptosis,  especially  if  the  lower  border  of  the  stomach  lies 
abnormally  low.  Sensitive  areas  can  also  be  determined  and  often 
the  presence  of  a  tumor. 

Percussion. — The  scratch  method  of  auscultatory  percussion  is 
serviceable  in  mapping  out  the  stomach,  as  is  also  auscultatory 
percussion. 

^  Medical  Record,  July  30,  1904. 

2  Archives  of  Physiological  Therapy,  Sept.,  1905. 


METHODS    OF    PHYSICAL    EXAMINATION    OF   THE    STOMACH  89 

Splashing  Sound. — If  not  present,  it  can  be  artificially  pro- 
duced, and  is  most  valuable  in  determining  the  lower  border  of  the 
stomach. 

Dehio's  Method. — Additional  water  can  be  given  if  desired, 
and  by  percussion  the  observations  determined  by  the  splashing 
sound  can  be  substantiated  for  accuracy. 

Gastrodiaphany. — This  can  be  employed  to  differentiate  in 
doubtful  cases  between  ptosis  and  dilatation,  and  is  of  value  in  accu- 
rately mapping  out  the  stomach  before  surgical  operation.  By  it 
one  can  at  times  determine  the  presence  of  a  tumor  at  an  early  stage. 

Inflation. — This  method,  especially  by  distention  with  carbonic 
acid  gas,  is  an  aid  in  mapping  out  the  stomach  and  in  determining 
the  position  of  the  upper  as  well  as  of  the  lower  border. 


CHAPTER  VI 

EXAMINATION  OF  THE  FUNCTIONS  OF  THE  STOMACH 

The  determination  of  the  functions  of  the  stomach — secretory, 
motor,  and  absorptive — is  of  importance  for  accurate  diagnosis. 
Of  the  examination  of  the  secretory  function  I  will  first  speak. 

Ewald  and  Boas  have  demonstrated  that  gastric  secretion  begins 
as  soon  as  food  enters  the  stomach,  and  continues  until  the  chyme 
has  passed  into  the  intestines.  The  secretion  is  diminished  toward 
the  last.  Examination  at  various  periods  after  taking  food  will 
give  different  results,  and  it  is  necessary  to  examine  the  gastric 
contents  at  a  definite  time,  during  the  height  of  digestion.  It  is 
desirable  that  a  definite  test  meal  should  be  administered. 

TEST  MEALS 

Riegel's  Test  Dinner. — Riegel's  test  dinner  is  the  oldest  advo- 
cated. This  consists  of  a  plate  of  meat  broth  (about  400  cc.) ;  a 
beafsteak  weighing  from  150  to  200  gm.  (5-7  ounces);  50  gm  (ij 
ounces)  of  mashed  potatoes;  and  a  roll   (35   gm.). 

The  average  time  one  should  aspirate  the  stomach  contents  is 
about  four  hours  after  this  meal. 

Ewald's  Test  Meal. — This  consists  of  about  6  ounces  (175  gm.) 
of  finely  chopped  meat;  stale  bread,  35  gm.,  and  butter,  to  be  taken 
three  hours  before  withdrawal  of  the  stomach  contents. 

This  is  practical  as  regards  quantity,  as  by  some  the  test  meal 
of  Riegel  is  considered  large  in  amount. 

Test  Meal  of  Germain  See. — The  patient  is  given  3  to  5  ounces 
(100-150  gm.)  of  white  bread;  2  to  3  ounces  (60-80  gm.)  of  finely 
chopped  meat,  and  a  large  glass  (300  cc.)  of  water;  and  the  contents 
examined  two  hours  later. 

Klemperer's  Test  Meal. — This  consists  of  i  pint  (500  cc.)  of 
milk  and  2  rolls  (70  gm.),  given  on  an  empty  stomach.  Examination 
two  hours  later. 

Test  Breakfast  of  Ewald  and  Boas. — This  is  given  in  the 
morning  in  the  fasting  condition,  and  consists  of  i  to  2  rolls  (35-70 
gm.)  and  i  cup  (300-400  cc.)  of  tea  or  water.  Examination  one 
hour  later. 

Boas'  Test  Breakfast. — One  ounce  of  rolled  oats  boiled  in 
I  pint  of  water,  with  salt  to  taste. 

Boas  advocates  this,  as  it  contains  no  lactic  acid,  and  believes 
it  should  be  employed  when  an  accurate  test  for  this  acid  is  desired. 

90 


EXAMINATION    OF   THE    FUNCTIONS    OF   THE    STOMACH  9 1 

Two  shredded  wheat  biscuits  with  water  (300  cc.)  or  a  pint  bowl 
of  granose  have  been  recommended  as  a  convenient  substitute. 

The  test  meals  that  are  in  chief  use  are  the  Riegel  test  dinner  and 
Ewald-Boas  test  breakfast.  The  latter  is  easily  procured  and  can 
be  administered  during  ofifice  hours — which  is  the  most  accurate 
method.  It  is  easy  to  recognize  therein  remnants  of  food  from  the 
previous  day.  The  test  dinner  gives  better  results  as  regards  the 
investigation  of  the  microscopic  appearances  and  the  study  of  the 
motor  functions.      The  test  breakfast  in  many  cases  will  be  sufficient. 

It  is  often  of  service  to  administer  a  special  test  dinner  at  7  p.  m. 
and  the  test  breakfast  in  the  office  at  7.30  to  8.00  a.m.  It  will  be 
described  under  Testing  the  Motor  Functions. 

I  agree  with  Fleiner  that  tea  is  to  some  an  irritant.  In  addition, 
it  is  not  of  stable  strength,  and  water  is  preferable.  The  average 
slice  of  bread  from  the  loaf  weighs  30  gm.  I  employ  usually  2  slices 
(60  gm.)  of  bread  and  250  to  300  cc.  of  water.  One  must  allow  for 
a  patient  of  small  physique  and  poor  nutrition,  for  in  such  cases  he 
cannot  or  will  not  take  this  quantity. 

The  diagnosis  in  most  cases  should  not  be  made  from  a  single 
examination  of  the  gastric  contents. 

METHOD  OF  ASPIRATION  OF  THE  GASTRIC  CONTENTS 

The  selection  of  the  proper  type  of  tube  is  important.  It  should 
be  of  soft  rubber,  of  a  caliber  of  30  to  32  French,  to  allow  free  exit 

^  -   -^ 

Fig.  48. — Aspirating  tube. 

of  contents;  have  an  opening  at  the  tip,  and  one  or  even  two  lateral 
openings,  as  in  Fig.  48,  or  the  Ewald's  tube  (Fig.  49). 


Fig.  49. — Ewald's  tube. 

Position  of  Patijent  and  Operator. — The  patient  sits  upright 
on  a  chair  and  is  protected  by  a  sheet  or  towel.  False  teeth  should 
be  removed.  The  operator  stands  in  the  position  as  depicted  in 
Fig.  50,  and  passes  the  tube  along  the  roof  of  the  patient's  mouth. 
The  advantages  of  this  method  are  described  under  Lavage. 


92 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


The  tube  should  be  moistened  in  warm  water  and  introduced 
about  20  inches  until  resistance  ,is  felt,  when  it  should  be  slightly 


Fig.  50. — Correct  position  for  passage  of  aspirating  tube. 

withdrawn.     In  the  event  of  gastroptosis  or  dilatation  the  distance 
would  be  greater.     A  Politzer  bulb  can  be  employed  for  aspiration. 


Fig.  51. — Boas'  aspirating  bulb. 

Boas'  Method. — The  Boas  aspirator  (Fig.  51),  which  consists  of 
a  rubber  bulb  having  two  soft-rubber  ends  and  provided  with  a 
clamp,  is  attached  to  the  stomach-tube  by  a  piece  of  glass  tubing. 
The  clamp  is  fixed,  the  bulb    compressed  and  then  released,  and 


EXAMINATION    OF   THE    FUNCTIONS    OF    THE    STOMACH 


93 


thus  filled  up;  the  clamp  is  opened,  and  the  contents,  by  com- 
pression of  the  bulb,  forced  into  a  bottle,  glass,  or  some  other  recep- 
tacle.     This  is  a  simple  method  of  aspiration.     Other  devices  with  a 


Fig.  52. — Aspirating  bulb 

vacuum    bottle,   mouth  suction,  forcing  air  through  a  double   tube, 
etc.,  have  been  suggested,  but  they  are  more  complicated. 


Fig-  53- — Filling  the  bulb. 

Ewald-Boas  Expression  Method. — This  consists  in  having 
the  patient  exert  pressure  upon  his  stomach  by  means  of  his  abdom- 
inal muscles.     He  should    first   inspire  deeply,  and  then  compress 


94 


DISEASES    OF   THE    STOMACH    AND   INTESTINES 


the  abdominal  walls  in  the  same  manner  as  during  defecation. 
The  pressure  expels  the  gastric  contents  through  the  tube  into  a  recep- 
tacle. This  method  is  considerably  employed,  and  when  successful 
is  unquestionably  excellent.  In  cases  of  marked  atony,  both  of  the 
stomach  and  abdominal  walls,  in  excessive  dilatation,  and  at  times 
from  plugging  of  the  stomach-tube,  the  expression  method  is  a 
failure. 

Author's  Method. — It  is  my  custom  to  attach  to  the  stomach- 
tube  a  bulb  without  valves,  such  as  is  depicted  in  Fig.  52.     The 


Fig.  54. — Second  step  of  aspiration. 


patient  is  then  directed  to  express  the  contents.  If  the  tube  becomes 
stopped,  the  thumb  is  placed  over  the  open  end,  the  bulb  squeezed, 
and  the  obstruction  immediately  relieved.  This  obviates  blowing 
through  or  removing  the  tube. 

If  expression  fails,  then  immediate  aspiration  is  resorted  to. 
The  tube  is  pinched  near  the  teeth,  the  bulb  squeezed,  and  the 
thumb  placed  over  the  open  end.  The  stomach-tube  is  then  released 
and  the  vacuum  in  the  tube  allowed  to  fill  with  gastric  contents, 
as  in  Fig.  53. 


EXAMINATION    OF    THE    FUNCTIONS    OF   THE    STOMACH 


95 


When  the  bulb  is  filled  the  stomach-tube  is  again  pinched,  the 
thumb  removed  from  the  bulb,  and  the  contents  gradually  expressed 
into  the  receiving  vessel,  as  in  Fig.  54. 


Fig-  55- — Final  step  of  aspiration. 

The  final  step  is  depicted  in  Fig.  55.      This   process  is  repeated 
until  the  gastric  contents  are  removed. 


EXAMINATION  OF  THE  INGESTA 

Before  chemic  examination  of  the  ingesta  is  begun,  the  quantity- 
aspirated  should  be  carefully  measured.  After  the  Ewald-Boas 
test  breakfast,  one  may  expect  to  secure  on  an  average  50  to  75  cc. 
of  contents,  and  if  100  cc.  or  more  be  present,  this  would  be  suggestive 
of  motor  insufficiency.  A  large  quantity  of  gastric  contents  (350  to 
400  cc.)  four  hours  after  the  test  dinner  would  also  be  a  suspicious 
circumstance,  and  further  tests  should  be  made,  as  described  under 
Examination  of  Motor  Functions.  The  quantity  of  the  residue, 
therefore,  has  a  chief  bearing  on  the  motor  function,  though  in 
hypersecretion  abnormal  quantities  are  found. 


96  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Macroscopic  inspection  gives  considerable  information.  After 
the  test  breakfast,  in  some  cases  large  undigested  pieces  of  bread  are 
brought  up;  in  others,  remnants  of  bread  that  are  nearly  digested 
or  only  slightlv  digested;  and  in  others,  a  fine  fluid  mushy  mass. 
These  findings  are  at  once  suggestive.  With  Riegel's  test  meal  the 
differences  are  more  pronounced;  the  mass  may  be  fine,  uniform, 
and  mushy,  containing  no  coarse  elements;  or  there  may  be  coarse 
undigested  meat-fibers. 

Mucus,  blood,  and  bile  are  readily  visible.  In  some  cases  the 
gastric  contents  when  placed  in  a  glass  vessel  forms  three  layers: 
at  the  bottom,  fine  starchy  material ;  next,  cloudy  fluid;  and  on  top 
a  foamy  layer,  which  latter  is  evidence  of  gaseous  fermentation. 

Chemic  Examination. — The  aspirated  gastric  contents  should 
be  filtered,  preferably  through  filter-paper.  If  this  is  not  at  hand, 
several  layers  of  cheese-cloth  or  gauze  can  be  employed. 

From  a  practical  point  of  view,  the  most  important  fact  to  deter- 
mine is,  whether  there  is  an  excess  of  hydrochloric  acid  during  the 
height  of  digestion.  If  free  hydrochloric  acid  be  present,  it  is  then 
necessary  to  find  out  whether  the  secretion  is  normal  or  increased. 
If  the  hydrochloric  acid  is  deficient  in  amount  or  absent,  the  digestive 
power  of  the  stomach  is  deficient. 

When  free  hydrochloric  acid  is  present,  the  determination  of 
pepsin  is  unnecessary;  in  fact,  it  is  often  present,  even  if  free  hydro- 
chloric acid  is  absent.  In  such  event,  if  the  gastric  contents  are 
acidified  with  sufficient  hydrochloric  acid  and  digestion  of  albumin 
then  occurs,  this  is  evidence  of  sufficient  pepsin  formation.  In 
cases  complicated  by  the  absence  of  free  hydrochloric  acid,  the 
examination  for  pepsin  should  be  carried  out. 

For  a  complete  chemic  analysis  the  following  tests  should  be 
performed : 

1.  Reaction. 

2.  Total  acidity. 

3.  Free  hydrochloric  acid. 

4.  Combined  hydrochloric  acid. 

5.  Lactic  acid. 

6.  Propepton. 

7.  Pepton. 

8.  Pepsin. 

9.  Rennet. 

10.  Dextrin. 

11.  Er3d:hrodextrin. 

12.  Achroodextrin. 

Before  describing  the  tests,  it  is  well  to  remember  the  findings 
of  the  normal  gastric  juice  after  the  test  breakfast  for  a  basis  of 
comparison. 

Normal  gastric  juice  is  of  acid  reaction;  total  acidity,  40  to  60 
(o.  1 5-0.21) ;  free  hydrochloric  acid,  25  to  50  (0.1-0.2  per  cent,  approxi- 


EXAMINATION    OF    THE    FUNCTIONS    OF    THE    STOMACH  97 

mately) ;  propepton,  small  amount;  pepton  more;  pepsin  and  rennet 
present;  sugar  and  achroodextrin,  present;  erythrodextrin  present 
in  small  amount  or  absent;  dextrin  absent. 

Some  patients  may  have  free  hydrochloric  acid  within  the  above 
normal  Umits,  and  yet  suffer  from  the  symptoms  of  hyperchlor- 
hydria;  while  others  may  have  free  hydrochloric  acid  as  high  as 
100+  and  present  no  symptoms  at  all.  Individual  peculiarities 
must  be  considered. 

Reaction. — This  is  determined  by  means  of  blue  and  red  litmus- 
paper.  If  the  filtrate  is  acid,  it  turns  the  blue  paper  red;  and  if 
alkaline,  the  red  turns  to  blue;  neutral  causes  no  change. 

Test  for  Free  Hydrochloric  Acid. — Numerous  coloring-matters 
when  exposed  to  the  action  of  weak  solutions  of  hydrochloric  acid, 
undergo  changes,  and  have  been  employed  as  tests  for  its  presence. 
Those  that  are  of  greatest  practical  value  I  wdll  describe  shortly. 

There  has  been  considerable  dispute  as  to  the  respective  superior- 
itv  of  these  tests.  Though  organic  acids,  when  present  in  considerable 
quantities,  may  give  these  color  changes,  yet  they  are  not  as  sensitive 
to  organic  acids  as  to  mineral  acids.  I  agree  with  Riegel  that  this 
danger  is  practically  negligible.  As  a  precaution  it  is  well  to  employ 
one  of  the  following  qualitative  check  tests,  w^hich  react  only  to  free 
mineral  acids,  and  not  to  the  organic  acids. 

In  addition,  the  test  for  lactic  acid  should  be  performed. 

The  Phloroglucin-vanillin  Test  (Glinzburg's). — This  reagent 
consists  of  2  grams  of  phloroglucin  and  i  gram  of  vanillin  dissolved 
in  30  grams  of  absolute  alcohol.  An  equal  number  of  drops,  i  or  2 
each,  of  this  and  the  gastric  juice  are  placed  on  a  porcelain  dish  and 
mixed  with  a  glass  rod.  The  dish  is  then  held  over  an  alcohol  lamp 
and  the  fluid  allowed  to  evaporate  slowly.  A  cherry-red  color 
appears,  as  in  Fig.  56,  if  free  hydrochloric  acid  be  present.  If  there 
are  only  traces,  then  there  is  a  rose  tint  at  the  margin.  If  hydro- 
chloric acid  is  absent,  the  color  varies  from  yellow  to  brown. 

This  test  responds  to  free  hydrochloric  acid  and  not  to  organic 
acids.  The  solution  is  unstable,  and  should  be  preserved  in  a  dark 
glass  bottle.     It  is  advisable  to  make  a  fresh  solution  frequently. 

The  Resjorcin-sugar  Test  (Boas). — Five  grams  of  resorcin  and 
3  grams  of  cane-sugar  are  dissolved  in  100  cc.  of  alcohol.  Equal 
drops  of  this  reagent  and  gastric  juice  are  slowly  evaporated  to 
dryness,  without  burning,  in  a  porcelain  dish  or  a  butter  dish.  If 
free  hydrochloric  acid  be  present,  a  rose-red  color  appears,  which 
fades  on  cooling  (Fig.  57).  It  responds  to  hydrochloric  acid  only. 
It  is  nearly  as  delicate,  more  easily  obtained,  less  expensive,  and 
more  stable  than  Giinzburg's  test. 

After  performing  one  of  these  check  tests  it  is  preferable  in  all 
cases  to  test  quantitatively  for  acidity;  and  for  this  purpose  I  prefer 
Topfer's  method. 

The  qualitative  method  gives  no  basis  for  scientific  accuracy. 


98  DISEASES    OF   THE   STOMACH   AND    INTESTINES 

Topfer's  Method. — This  method  determines  quantitatively: 
Total  acidity;  free  hydrochloric  acid;  combined  hydrochloric  acid; 
total  hydrochloric  acid,  and  acid  salts  quite  accurately  for  clinical 
purposes.  In  routine  examinations  it  is  rarely  necessary  to  deter- 
mine more  than  total  acidity  and  free  and  combined  hydrochloric 
acid.  If  free  acid  is  absent  then  the  pepsin  and  rennet  tests  should 
be  made. 

Solutions  Required. —  (i)  One  per  cent,  alcoholic  solution  of 
phenolphthalein  (colorless). 

(2)  One  per  cent,  aqueous  solution  of  sodi,um  alizarin  sulphonate 
(opaque  brownish  yellow). 

(3)  Five-tenths  per  cent,  alcoholic  solution  of  dimethyl-amido- 
azobenzol  (yellowish  red). 

(4)  Decinormal  solution  of  NaOH  to  titrate  the  gastric  juice; 
I  cc.  of  tenth-normal  XaOH  neutralizes  .00365  hydrochloric  acid. 

Topfer's  method  depends  upon  the  different  sensitiveness  of  three- 
color  end-reagents  to  the  various  constituents  of  the  gastric  juice. 

Method. — Though  10  cc.  of  the  filtrate  are  usually  employed, 
I  have  illustrated  the  method  on  the  basis  of  5  cc,  as  it  is  often 
practically  found  impossible  to  carry  out  all  the  tests  when  using 
larger  quantities.     The  methods  are  equally  correct. 

In  each  of  the  three  beakers  {A,  B,  and  C,  Fig.  58)  are  placed 
5  cc.  of  the  filtered  gastric  contents. 

To  beaker  A  are  added  i  to  2  drops  of  the  phenolphthalein  solution, 
which  is  used  as  an  indicator  of  the  total  acidity. 

This  body  turns  red  pink  or  red  as  soon  as  the  fluid  becomes 
slightly  alkaline,  after  the  addition  of  the  sodium  hydrate. 

To  beaker  C  we  add  1  to  2  drops  of  the  dimethyl-amido-azobenzol 
solution. 

A  reddish-pink  or  cherry-red  color  develops  if  free  hydrochloric 
acid  be  present,  depending  on  the  degree  of  acidity.  After  titration 
with  sodium  hydrate,  the  end-reaction  is  a  pale  orange  yellow. 

To  beaker  B  is  added  i  to  2  drops  of  the  sodium-alizarin-sidphonate 
solution.  After  sufficient  sodium  hydrate  is  added  a  violet  color 
(the  end-reaction)  appears. 

The  titration  with  sodium  hydrate  is  performed  from  a  graduated 
pipet  or,  preferably,  a  buret,  supported  on  a  stand.  The  latter 
should  be  graduated  to  i  or,  by  preference,  to  -^^  cc. 

The  elements  combining  the  total  acidity  in  beaker  A,  Fig.  58, 
are  free  h3-drochloric  acid,  acid  salts,  combined  hydrochloric  acid 
and  organic  acids,  which  respond  to  the  phenophthalein  test. 

In  beaker  B  are  free  hydrochloric  acid,  acid  salts,  and  organic 
acids,  responding  to  the  alizarin  test. 

Hence,  as  Topfer  claims,  to  find  the  combined  hydrochloric  acid, 
one  must  substract  the  acidity  of  B  from  the  total  acidity  of  A. 

In  beaker  C  we  have  free  hydrochloric  acid  alone,  which  responds 
to  the  dimethvl-amido-azobenzol  test. 


Fig.  57. — Resorcin  test.     Color 
reaction. 


Fig.  56. — Phloroglucin-vanillin  test. 
Color  reaction. 


Sc.c.Gastric  Juice 


Sc.c.GastricJuice 


Sc.c.GastricJuice 


PHENOLPHTHALEIN. 


1.  Frtf  HCL 

2.  Acid  Salts. 

j».  Organic  Acids, 
4.  Combined  HCi. 


1.  Free  HCL 

2.  Acid  Salts. 

J.  Organic  Acids. 


Af/IIDO-BENZOL. 

YlLUrW  Ams  XXUTKA 

/.  Free  HCL 


Fig.  58. 


Fig.  59. — Phenolphtha- 
lein  end-reaction.  Total 
acidity. 


Fig.  61. — vSodium  ali- 
zarin sulphonate  end-re- 
action. 


Fig.  60. — Dimethyl- 
am  ido-azobenzol  end- 
reaction. 


EXAMINATION    OF    THE    FUNCTIONS    OF   THE    STOMACH  99 

In  the  absence  of  organic  acids,  the  acidity  of  C  substracted  from 
the  acidity  of  B  will  give  the  acid  salts. 

Total  Acidity. — The  beakers  being  thus  prepared,  titration  of 
beaker  A  (total  acidity)  is  begun  with  the  sodium  hydrate  solution. 
As  this  is  added,  the  reddish  color  appears,  but  it  disappears  as  the 
fluid  is  agitated.  The  procedure  should  be  continued  until  a  per- 
manent  red-pink   or   reddish   color   is   present,   as   in   end-reaction 

(Fig-  59)- 

As  the  degree  of  acidity  is  expressed  by  the  number  of  cubic 
centimeters  of  a  decinormal  solution  of  sodium  hydrate  required  to 
saturate  or  make  slightly  alkaline  100  cc.  of  the  gastric  contents,  and 
as  only  5  cc.  of  the  latter  was  employed  (which  is  ^o  of  the  total 
quantity) ,  the  number  of  centimeters  of  the  sodium  hydrate  necessary 
to  produce  the  end-reaction  must  be  multiplied  by  20. 

Thus  if  3  cc.  sodium  hydrate  produced  the  end-reaction  in  5  cc. 
of  the  filtrate,  the  total  acidity  would  be  3X20,  or  60 -H. 

iNIultiply  this  figure  of  acidity  by  0.00365,  and  we  have  the 
percentage  of  total  hydrochloric  acid,  or  60X0.00365  equals  0.219 
per  cent. 

Free  Hydrochloric  Acid. — Commence  titration  of  beaker  C,  to 
which  the  dimethyl-amido-azobenzol  solution  has  been  added,  and 
continue  titration  until  the  solution  becomes  a  pale  lemon  yellow, 
as  in  Fig.  60. 

As  saturation  with  the  decinormal  sodium  hydrate  solution  was 
computed  on  the  basis  of  100  cc.  of  .gastric  contents,  and  only  5  cc. 
or  YW  were  tested,  the  number  of  cubic  centimeters  of  sodium  hydrate 
solution  required  to  produce  the  end-reaction  must  be  multiplied  by  20. 

Thus,  if  2  cc.  of  this  alkahne  solution  will  produce  this  result, 
we  must  multiply  it  by  20,  and  we  say  the  free  hydrochloric  acid 
is  40  -|- . 

To  compute  free  hydrochloric  acid  in  percentage,  multiply 
40X0.00365=0.1460  per  cent. 

Combined  Hydrochloric  Acid. — Commence  titration  of  beaker  B, 
to  which  the  sodium-alizarin-sulphonate  has  been  added,  and  con- 
tinue the  process  until  the  end-reaction,  the  violet  color,  as  in  Fig. 
61,  occurs.    ' 

As  only  5  cc.  of  gastric  contents  are  employed,  and  again  the 
computation  is  based  on  100  cc,  the  number  of  cubic  centimeters 
of  decinormal  sodium  hydrate  employed  must  be  multiphed  by  20. 

If,  for  example,  2.2  cc.  were  required,  2. 2X20  =  44-!- acidity. 

Topfer  has  shown  that  alizarin  is  sensitive  for  all  the  elements 
comprising  acidity,  except  for  the  combined  hydrochloric  acid. 

The  acidity  44,  therefore,  secured  by  this  reaction  nmst  be 
substracted  from  60,  the  total  acidity;  and  this  gives  16  acidity  as 
the  combined  hydrochloric*  acid. 

In  percentage  16X0.00365  =  .06  per  cent,  combined  h3^drochloric 
acid. 


loo  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

The  total  acidity,  free  and  combined  hydrochloric  acid,  are 
important  to  examine  for  as  a  matter  of  routme. 

As  fractions  of  a  centimeter  must  often  be  computed,  I  give  an 
example  in  tabulated  form : 

Beaker  A,  5  cc.  gastric  contents;  for  total  acidity,  3.2  cc.  deci- 
normal   sodium   hydrate   gives   end-reaction. 

Beaker  B,  5  cc.  gastric  contents;  for  alizarin  test,  2.4  cc.  deci- 
normal  sodium  hydrate  gives  end-reaction. 

Beaker  C,  .5  cc.  gastric  contents;  for  free  hydrochloric  acid,  1.5  cc. 
decinormal  sodium  hydrate  gives  end-reaction. 

1.  Total  Acidity.  Beaker  A. — 5  cc.  X20=  100  cc.  3.2  cc.  X20 
^64  cc.     64X0.00365  =  .23  per  cent. 

2.  Free  Hydrochloric  Acid.  Beaker  C. — 1.5  cc.  X2o  =  30  cc.  30 X 
0.00365  =  . II  per  cent. 

3.  Combined  Hydrochloric  Acid=  A-B. — 
B  =  alizarin  reaction.     A  =64. 
2.4X20  =  48.  ^  =  48 

A-S  =  i6  =  combined  HCl. 
16X0.00365  =  .06  per  cent. 

4.  Total  Hydrochloric  Acid,  Free  and  Combined. — .11  per  cent. 
+  .06  per  cent.  =  .17  per  cent. 

5.  Acid  Salts  =  B  —  C   (Organic  Acids  Absent). — 

5  =  48 
C  =  3-0 

B-C=i8 

S-C=i8 

18X0.00365  =  .07  per  cent. 

If  10  cc.  of  gastric  juice  be  employed  in  the  tests,  then  the  number 
of  cubic  centimeters  of  sodium  hydrate  required  to  produce  the  end- 
reaction  must  be  multiplied  by  10. 

If  2  cc.  of  gastric  juice  is  used,  the  multiple  is  50,  and  so  on. 

The  further  tests  are  as  follows : 

Lactic  Acid. — Ufjelmann's  Test. — This  reagent  is  the  one  most 
frequently  employed  and  is  sufhciently  accurate,  if  necessary  pre- 
cautions are  observed.  It  should  be  freshly  prepared  before  each 
test.  It  can  be  prepared  as  follows:  10  cc.  of  a.  4.  per  cent,  carbolic 
acid  solution  is  mixed  with  20  cc.  of  distilled  water,  and  to  this  is 
added  i  drop  of  sesqidchlorid  of  iron.  A  watery  solution  of  carbolic 
acid  (2  per  cent.),  to  which  is  added  i  drop  of  liquor  ferri  sesqui- 
chlorid,  is  another  method  of  preparation.  These  solutions  have  an 
amethyst-blue  color. 

Other  methods  of  preparation  are  recommended  by  Riegel: 
20  cc.  of  distilled  water,  locc.  of  a  4  per  cent,  carbolic  acid  solution, 
and  o.i  cc.  of  neutral  10  per  cent,  iron  chlorid  solution;  or,  dilute 
the  officinal  iron  chlorid  solution  with  distilled  water  until  the 
solution  is  about  colorless,  and  then  add  a  2  to  4  per  cent,  solution 
of  carbolic  until  the  amethyst-blue  color  appears. 


Fig.  62. 


Fig.  63. 


Fie.  62. 
Fig.  63 


-Uffelmann's  test. 
-Congo  red  test. 


EXAMINATION    OF   THE    FUNCTIONS    OF    THE    STOMACH 


lOI 


A  very  dilute  iron  chlorid  solution  will  also  give  the  reaction, 
but  the  blue  color  acts  as  a  contrast. 

The  lactic  acid  reaction  has  been  described  as  a  canary-yellow 
or,  more  often,  a  canary-green  color  (Fig.  62). 

Fatty  acids  produce  an  ash-gray  and  inorganic  acids  decolorize 
the  blue  solution. 

As  at  times  the  phosphates  may  be  present  in  the  gastric  contents, 
and  they  give  the  same  reaction,  a  modification  has  been  recom- 
mended, which  is  practical  for  general  use. 

Modified  Uffelmann. — ^Take    5   cc.  of   the  fil-  

trate  plus   10  cc.  of  ether,  and  shake  in  a  test-  ^      ^ 

tube  for  a  few  minutes;  then  allow  it  to  stand 
until  the  ethereal  solution  has  separated  from 
watery  solution.  Pour  the  ethereal  part  into  an- 
other test-tube  and  place  it  in  a  glass  of  hot 
water  to  evaporate.  Add  i  cc.  of  distilled  water 
to  the  remaining  drops,  and  test  for  lactic  acid 
with  the  Uffelmann  solution.  If  the  canary  color 
occurs,  lactic  acid  is  positively  shown. 

A  larger  quantity  of  the  filtrate  can  be  em- 
ployed with  two  or  three  times  the  quantity  of 
ether.  Fleiner  does  not  evaporate  the  ether, 
but  adds  Uffelmann 's  solution  directly  to  it.  The 
solution  will  appear  yellow  at  the  bottom  of  the 
tube  if  lactic  acid  be  present. 

Strauss  employs  a  mixing  funnel  with  two 
markings,  one  at  5  cc.  and  the  second  at  25  cc. 
(Fig._64). 

Fill  to  5  cc.  with  the  stomach  filtrate.  Pour 
on  ether  (Squibbs)  up  to  25  cc.  and  shake  the 
mixture  well.  Open  the  lower  stop-cock  and 
allow  the  fluid  to  run  off  until  it  reaches  5  cc, 
and  then  pour  in  distilled  water  to  25  cc.  To  this 
mixture  add  2  drops  of  iron  chlorid  solution  (1:9 
distilled  water),  and  shake  the  whole. 

Investigations  by  Strauss  show  that  if  one  promillimeter  of  lactic 
acid  be  present,  an  intense  green  color  occurs;  if  less  lactic  acid,  the 
color  is  light  green. 

Arnold^  suggests  a  new  test : 

1.  A  solution  of  gentian  violet  (0.2  cc.  saturated  alcoholic  solu- 
tion in  500  cc.  distilled  water)  and 

2.  Tincture  ferri  perchloridi,  5  cc.  (U.  S.  P.),  diluted  with  dis- 
tilled water  (20  cc). 

A  drop  of  the  iron  solution  gives  a  blue  color  with  i  cc.  of  the 
gentian  violet,  which  changes  to  yellowish  green  when  gastric 
contents  which  contain  lactic  acid  are  added. 

1  Journal  of  American  Medical  Association,  1898,  vol.  viii,  p.  21. 


\^!Il 


Fig.  64. — Strauss 
mixing  funnel. 


I02  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Other  methods  have  been  suggested,  notably  that  of  Boas,  which 
is  rather  compHcated.  It  is  based  on  the  oxidation  of  lactic  acid 
into  acetaldehyd  and  formic  acid. 

The  presence  of  aldehyd  is  demonstrated  by  the  iodoform  reaction 
with  alkaline  iodin  solution,  or  of  aldehyd  of  mercury  with  Nessler's 
reagent. 

Boas  Method. — Take  lo  to  20  cc.  of  the  gastric  filtrate  and 
evaporate  it  into  a  syrupy  consistency  over  the  water-bath.  If 
free  hydrochloric  acid  is  present,  an  excess  of  barium  carbonate  is 
added.  A  few  drops  of  phosphoric  acid  are  then  mixed  in,  and  the 
carbonic  acid  is  expelled  by  boiling.  The  fluid  is  then  cooled  and 
extracted  two  or  three  times  with  5p  cc.  of  ether. 

After  half  an  hour  pour  off  the  clear  ethereal  layer.  The  ether 
is  now  evaporated  and  the  residue  washed  in  a  flask  with  45  cc.  of 
water,  well  shaken  and  filtered.  Concentrated  sulphuric  acid, 
5  cc.  (sp.  gr.  1.89),  and  a  pinch  of  manganese  dioxid  are  added  to 
the  filtrate.  The  mixture  is  then  distilled  over  a  small  flame,  and 
the  vapor  conducted  into  a  narrow  cylinder  containing  5  to  10  cc. 
of  an  alkaline  iodin  solution.  This  consists  of  equal  parts  of  a 
decinormal  iodin  solution  and  the  standard  potassium  hydrate 
solution.  The  vapor  may  be  conducted  into  the  same  quantity  of 
Nessler's  reagent.  If  lactic  acid  is  present  it  gives  rise  to  the  iodoform 
reaction  (clouding  and  odor  of  iodoform)  with  the  iodin  mixture. 
If  Nessler's  reagent  is  used,  yellowish-red  aldehyd  of  mercury 
appears. 

This  procedure  is  further  elaborated  for  the  quantitative  estima- 
tion of  lactic  acid,  but  it  is  extremely  complicated  and  clinically 
unnecessary. 

We  may  say  that  when  a  test  breakfast  or  test  dinner  is  taken  imder 
proper  conditio7is,  only  traces  of  lactic  acid  are  introduced,  and  finding 
it  in  appreciable  quantities  in  the  gastric  contents  is  of  pathologic 
significance,  showing  subacidity  and  stagnation.  It  is  not  pathog- 
nomonic of  cancer,  but  these  conditions  frequently  exist  in  such 
cases. 

Quantitative  Estimation  of  Lactic  Acid. — The  acidity  of  the  filtrate 
is  first  determined ;  10  cc.  of  the  filtrate  are  shaken  up  with  ether 
in  excess.  The  ether  is  then  separated  and  the  degree  of  acidity 
computed  therein. 

Subtract  this  figure  from  the  total  acidity  and  multiply  by  .09, 
which  gives  the  percentage. 

Volatile  acids  must  be  first  tested  for  and  eliminated  by  boiling. 
This  method  is  only  approximate. 

Volatile  Acids. — Fatty  or  volatile  acids  are  recognized  by 
boiling  a  few  cubic  centimeters  of  the  filtrate  in  a  test-tube.  A  strip 
of  moistened  blue  litmus-paper  is  held  over  the  escaping  vapors. 
The  paper  will  turn  red  if  they  are  present.  Their  quantitative 
determination  is  hardly  necessary. 


EXAMINATION    OF    THE    FUNCTIONS    OF    THE    STOMACH  103 

Acetic  Acid. — In  large  quantities  acetic  acid  can  be  detected 

by  its  characteristic  odor.  For  the  detection  of  small  quantities, 
Einhorn  neutralizes  the  watery  residue  of  the  ethereal  extract  of 
the  gastric  filtrate  with  carbonate  of  soda,  and  then  adds  neutral 
chlorid  of  iron  solution,  when  a  red  color  is  developed. 

Propepton. — Add  to  the  gastric  filtrate  of,  say,  5  cc.  an  equal 
quantity  of  a  saturated  solution  of  sodium  chlorid.  Propepton, 
if  present,  is  precipitated.  If  none  is  formed,  then  add  i  or  2  drops 
of  acetic  acid,  and  precipitation  will  occur  if  propepton  is  present. 
On  heating,  the  solution  clears  up,  but  again  becomes  turbid  on 
cooHng. 

Pepton. — Preferably,  after  filtering  out  the  propepton,  take 
2  cc.  of  the  gastric  filtrate  and  make  strongly  alkaline  by  adding 
sodium  hydrate  solution  and  then  add  a  few  drops  of  a  weak  i  per 
cent,  copper  solution.  Pepton  gives  a  purple  or  violet-red  color 
(biuret  reaction). 

Pepsin. — A  thin  disk  of  the  white  of  a  hard-boiled  egg,  weight 
of  about  I  gram  (i  cm.  in  diameter  and  i  mm.  thick),  is  placed  in  a 
test-tube  containing  5  cc.  of  the  gastric  filtrate  and  kept  at  blood 
temperature.  The  tube  can  be  placed  in  water  at  blood  temperature 
in  a  Thermos  bottle. 

If  free  hydrochloric  acid  is  not  present  in  the  filtrate,  add  2  drops 
of  dilute  hydrochloric  acid.  The  presence  of  pepsin  will  cause 
disappearance  of  the  albumin  in  from  two  to  six  hours. 

The  methods  for  the  quantitative  determination  of  pepsin  that 
have  been  recognized  as  practical  for  clinical  purposes,  are  those  of 
Hammerschlag  and  Mett.  Henry  Illoway  has  devised  a  simple 
method  for  determining  the  relative  quantity  of  pepsin,  which  seems 
to  the  author  of  value:  10  cgm.,  exact  weight,  egg  albumen  (white 
of  hen's  egg)  is  coagulated  in  the  following  manner : 

The  egg  is  placed  in  a  small  pot  of  cold  water,  which  is  then 
covered  with  a  lid  and  put  on  to  boil.  It  is  allowed  to  cook  for  ten 
minutes  after  the  water  has  begun  to  boil — in  all,  twenty  minutes 
from  the  time  it  has  been  put  on.  The  egg  is  then  taken  out  and 
allowed  to  cool,  either  by  setting  it  in  a  saucer  or  by  putting  it  into 
cold  water. 

To  imitate  the  usual  way,  food  is,  or  should  be,  ingested,  the 
segment  of  albumin  is  divided  into  two  parts.  Observation  has 
shown,  as  it  has  long  been  known  cHnically,  that  thus  subdivided 
the  gastric  juice  can  act  upon  it  more  quickly.  The  action  being 
from  all  sides,  it  is  m.ore  effective  when  we  have  eight  sides  for  a 
given  quantity,  than  where  we  have  only  four. 

The  coagulated  albumin  is  put  into  10  cc.  of  the  gastric  filtrate 
(from  stomach  contents  extracted  one  hour  after  an  Ewald-Boas 
test  breakfast),  and  this  is  then  placed  in  the  thermostat,  which  is 
kept  at  38°  C. 

The  time  in  which  the  10  cgm.  are  digested,  entirely,  partially, 


I04  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

or  not  at  all,  will  give  us  a  correct  idea  as  to  the  status  of  the  pepsin 
secretion  in  the  case  under  examination.  Illoway  by  experiments 
shows  that  normal  digestion  of  the  albumin  requires  from  five  to 
five  and  one-half  hours. 

He  classifies  as  follows : 

Hyperpepsinia. — Digestion  requiring  only  from  three  to  four 
hours,  not  in  any  pathologic  sense  necessarily,  but  only  to  indicate 
a  secretion  of  pepsin  greater  than  usual;  which  may,  however,  be 
the  normal  for  that  case. 

Normal  Pepsinia. — Digestion  requiring  from  five  to  five  and 
one-half  hours. 

Hypopepsinia. — Digestion  requiring  more  than  the  usual  time. 
The  degree  indicated  b}^  the  number  of  hours  required  beyond  the 
standard  of  time. 

Apepsinia. — No  digestion  at  all. 

Jacoby-Solms  Method  to  Determine  Pepsin. — Ricin  Test} — - 
Dissolve  i.o  gram  of  ricin  in  loo  cc.  of  a  5  per  cent,  solution  of  sodium 
chlorid  and  filter.  Mix  2  cc.  of  this  filtrate  with  0.5  cc.  decinormal 
HCl  solution ;  i  cc.  of  diluted  stomach  contents  is  added  and  allowed 
to  remain  at  blood  temperature  for  three  hours.  Ferments  clear 
up  the  ricin  deposit.  The  quantity  of  pepsin  is  determined  from 
the  amount  of  dilution  in  which  the  stomach  contents  will  cause  the 
ricin  deposit  to  disappear. 

Solms  designates  the  amount  of  gastric  juice  which  is  sufficient 
to  clear  up  the  2  cc.  of  a  2  per  cent,  ricin  solution  in  three  hours, 
kept  at  the  blood  temperature,  as  one  pepsin  unit.  The  normal 
stomach  contents  contain  about  100  pepsin  units  to  the  cubic  centi- 
meter. 

Fuld  employs  a  solution  of  edestin  instead  of  ricin.- 

An  ordinary  Thermos  bottle  partially  filled  with  water  at  a 
temperature  of  about  100°  F.  can  be  employed  in  place  of  a  thermo- 
stat; test-tubes  containing  the  solutions  being  tightly  corked  and 
placed  therein.  Einhorn^  employs  a  Thermos  bottle  with  metal 
framework  to  hold  the  tubes.  These  last  are  graduated  in  milli- 
meters, so  as  to  dispense  with  measuring  glasses. 

Casein  Test. — Gross*  mixes  a  i :  looo  solution  of  casein  containing 
16  cc.  of  a  25  per  cent.  HCl  to  the  liter  with  the  filtrate  or  its  dilutions, 
and  leaves  it  for  a  quarter  of  an  hour  in  the  thermostat. 

He  then  adds  a  few  drops  of  the  concentrated  solution  of  sodium 
acetate,  which  results  in  a  precipitate  if  the  casein  has  not  been 
digested;  otherwise  the  solution  remains  clear. 

^  "  Ueber  eine  neue  methode  der  quantitative  Pepsinbestimmung  und  ihre 
Klinishe  verwendung,"  Zeitschr.  f.  klin  Med.,  Bd.  64,  Heft  i  and  2. 

2  "  Pepsinbestimmung  vermittelst  Edestins,"  Miinchener  med.  Wochenschr., 
1907,  No.  27,  Vereinsbeilage. 

^Einhorn  "A  simplification  of  the  Jacoby-Solms  Ricin  Method  for  Pepsin 
Determination."  Med.  Record,  Aug.  29,  igoS. 

*  "  Die  Wirksamkeit  des  Pepsins  und  eine  einfache  methode  zu  ihrer  Bestim- 
mung,"  Berliner  klin.  Wochenschr,  1908.  No.  13,  p.  643. 


EXAMINATION    OF    THE    FUNCTIONS    OF    THE    STOMACH  105 

Melt's  Method. — This  consists  in  sucking  fresh  egg  albumen  into 
capillary  tubes  of  i  or  2  mm.  diameter,  coagulating  the  albumen 
by  boiling,  and  then  cutting  off  portions  3  to  5  cm.  long  of  the  filled 
tube  and  adding  these  pieces  to  the  gastric  contents.  This  should 
be  kept  at  body  temperature  for  ten  hours  in  the  incubator.  At 
the  end  of  this  period  each  end  of  the  tube  will  show  a  lack  of  solid 
albumen  owing  to  digestion,  while  some  will  remain  in  the  central 
portion.  Both  the  empty  portions  and  the  portion  that  is  full  are 
measured,  and  the  activity  of  the  pepsin  digestion  is  thus  determined. 
The  relative  amount  of  pepsin  varies  according  to  the  square  of  the 
length  of  the  empty  portion  of  the  tube,  the  figures  of  the  latter  being 
expressed  in  millimeters;  thus,  3  mm.  of  digestion  equals  9  parts  of 
pepsin;  2  mm.,  4  parts  of  pepsin,  etc. 

Rennet. — x\dd  5  drops  of  the  filtered  gastric  contents,  preferably 
neutralized  with  decinormal  sodium  hydrate  solution,  to  10  cc.  of 
fresh  neutral  milk  in  a  test-tube.  Place  this  in  a  glass  of  warm  water 
at  a  temperature  of  about  100°  F.,  or  in  a  thermostat.  A  Thermos 
bottle  containing  warm  water  is  extremely  convenient. 

Normal  Rennet. — In  about  five  to  fifteen  minutes  coagulation 
will  occur  if  the  rennet  be  normal.  If  the  same  quantity  of  filtrate 
(5  drops)  be  added  to  20  cc.  of  milk,  Illoway  finds,  under  normal 
conditions,  coagulation  will  occur  within  fifteen  to  thirty  minutes. 
He  suggests  a  simple  quantitative  method. 

Deficient  Rennet. — Add  i  cc.  of  gastric  filtrate  to  10  cc.  and  20  cc. 
of  milk,  if  the  smaller  quantity  of  filtrate  (5  drops)  gives  no  result^ 
If  reaction  occurs  within  the  same  period,  rennet  is  deficient. 

More  marked  deficiency  when  no  result  is  obtained  with  i  cc.  of 
gastric  filtrate,  but  is  obtained  within  the  half -hour  with  5  cc.  of 
filtrate. 

Absence  of  Rennet. — When  no  reaction  is  obtained  within  half  an 
hour  with  5  cc.  of  gastric  juice  and  10  cc.  of  filtrate,  no  reaction  will 
occur. 

It  has  been  demonstrated  by  Illoway's  experiments  that  rennet 
may  be  present  in  nearly  normal  amount,  even  if  pepsin  is  markedly 
deficient ;  it  may  be  present  even  if  pepsin  is  absent. 

Rennet  is  usually  the  last  one  of  the  elements  active  in  the 
process  of  gastric  digestion  to  disappear. 

Rennet  Zymogen  {Chymosinogen). — Add  to  the  same  specimen  of 
milk  3  to  5  drops  of  a  i  per  cent,  solution  of  calcium  chlorid  and 
place  in  an  incubator.  Coagulation  shows  the  presence  of  the  enzyme ; 
otherwise  it  is  absent. 

Examination  of  Starch  Digestion. — The  salivary  ferment 
continues  its  action  on  starch  in  the  stomach  while  the  amount  of 
hydrochloric  acid  is  not  too  great.  It  is  estimated  that  as  soon  as 
the  total  hydrochloric  acid  reaches  0.12,  the  action  ceases.  If  the 
secretion  of  hydrochloric  acid  is  abnormally  great,  starch  diges- 
tion is  soon  stopped,  and  there  is  either  no  digestion  of  starch  or 


I06  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

the  end-products  are  not  formed.  The  reverse  is  the  case  in  sub- 
acidity. 

To  determine  the  intermediary  stages,  a  dilute  iodin-potassium 
solution  (Lugol's)  is  employed.  It  consists  of  iodin,  o.i;  potassium 
iodid,  0.2 ;  aqua  destillata,  200.0. 

A  few  drops  of  the  filtered  gastric  juice  are  placed  on  a  porcelain 
dish,  and  to  it  is  added  a  drop  or  two  of  Lugol's  solution.  The 
reactions  are  as  follows : 

Dextrin  turns  the  fluid  blue;  erythrodextrin,  a  red  purple; 
achroodextrin  discolors  slightly  the  yellow  tincture  of  the  Lugol; 
maltose  does  not  change  the  color. 

For  sugar  or  maltose,  FehHng's  or  Trommer's  test  must  be 
employed. 

In  normal  cases,  sugar  and  achroodextrin  are  present;  erythro- 
dextrin absent  or  present  in  small  amount;  dextrin  absent. 

If  blue  or  blue-violet  color  appear,  saccharification  is  deficient. 

Other  Methods  for  Determining  Free  Hydrochloric  Acid. — 
It  seems  advisable  to  describe  a  few  additional  practical  methods 
of  determining  free  hydrochloric  acid: 

1.  Tropdolin  00  (]\Ierck's)  in  a  concentrated  watery  solution, 
as  recommended  by  Riegel.  Knapp  employs  a  supersaturated 
alcoholic  solution  of  the  same. 

To  5  cc.  of  the  filtered  chyme  add  2  drops  of  the  tropaiolin  solution. 
Free  hydrochloric  acid  turns  it  a  cherry-red.  Titrate  with  decinor- 
mal  sodium  hydrate  until  it  becomes  amber — the  end-reaction. 

As  5  cc.  is  2V  of  100,  on  which  the  calculation  is  based,  and  if 
it  takes  3  cc.  of  the  alkali  to  produce  the  end-reaction,  free  hydro- 
chloric acid  therefore  =  20  X  3  =  60. 

Multiply  60X0.00365  to  secure  percentage. 

2.  Mintz's  Method. — For  example,  to  10  cc.  of  the  gastric  filtrate, 
decinormal  sodium  hydrate  is  gradually  added,  until  i  drop  of  the 
mixture  no  longer  responds  to  the  Giinzburg  reaction  (phloroglucin- 
vanillin  test).  A  platinum  loop  should  be  employed  as  a  drop 
carrier. 

The  amount  of  the  sodium  hydrate  solution  in  this  case  should 
be  multiplied  by  10  to  give  free  hydrochloric  acid. 

For  example,  if  the  reaction  no  longer  appears  after  the  addition 
of  3  cc.  sodium  hydrate,  free  hydrochloric  acid  =  30;  percentage 
=  30X0.00365,  or  0.109  per  cent. 

3.  Boas  and  Moerner. — They  estimate  the  free  hydrochloric  acid 
by  Congo  paper,  or  by  a  i  per  cent,  watery  solution  of  Congo  red, 
which  turns  blue  in  the  presence  of  this  acid  (see  reaction.  Fig.  63). 

Take  5  cc.  of  the  filtrate  and  add  3  or  4  drops  of  the  Congo  red 
solution.     More  is  unnecessary,  though  Boas  adds  5  cc.  of  it. 

On  the  other  hand,  Congo  paper  can  be  moistened  in  the  filtrate. 
A  blue  reaction  results  in  each  case. 

Decinormal  sodium  hvdrate  is  then  added  to  the  mixture,  or  the 


EXAMINATION    OF   THE    FUNCTIONS    OF    THE    STOMACH  I07 

paper  is  placed  in  a  porcelain  dish  and  the  alkali  added.  Titration 
is  continued  until  the  blue  begins  to  turn  red.  The  estimation  is 
performed  in  the  same  way  as  before. 

4.  RiegeVs  Method. — Congo  paper  is  employed  in  his  test. 

Take  10  cc.  of  the  gastric  filtrate.  The  Congo  paper  is  dipped  in 
the  filtrate,  giving  the  blue  reaction  of  free  hydrochloric  acid.  It  is 
then  placed  on  a  saucer.  Decinormal  sodium  hydrate  is  allowed  to 
drop  slowly  from  the  buret  into  the  filtrate,  and  a  drop  of  the  mixture 
is  removed  from  time  to  time  with  the  platinum  loop  and  applied  to 
the  Congo  paper.  As  the  change  in  color  becomes  indistinct,  this 
is  controlled  by  dropping  distilled  water  on  the  same  piece  of  paper. 
The  alkali  is  dropped  on  the  paper  until  it  begins  to  turn  a  violet  red. 

The  number  of  cubic  centimeters  of  decinormal  sodium  hydrate 
necessary  to  secure  the  end-reaction,  say  3  cc,  is  multiplied  by  10, 
giving  free  hydrochloric  acid  as  30.  This  is  necessary,  as  the  orig- 
inal figure  is  computed  for  100  cc.  of  contents,  and  only  10  cc.  were 
employed. 

To  complete  the  analysis  and  estimate  the  total  acidity,  2  drops 
of  phenolphthalein  solution  are  added  to  the  same  filtrate,  and  titra- 
tion with  the  sodium  hydrate  is  continued  until  the  color  of  the 
solution  turns  red   (the  end-reaction). 

The  total  acidity  is  indicated  by  the  total  quantity  of  decinormal 
sodium  hydrate  used  from  the  beginning  of  the  first  titration.  For 
example,  if  in  both  titrations  6  cc.  of  sodium  hydrate  have  been 
employed,  the  total  acidity  is  60,  as  10  cc.  of  filtrate  were  examined. 

Various  modifications  have  been  employed  for  these  tests,  which 
only  serve  to  confuse  the  reader.  Those  described  are  the  most 
practical. 

Small  booklets  of  Congo  paper  can  be  secured  from  Merck.  It 
may  be  prepared  by  saturating  filter-paper  with  a  watery  solution. 
It  is  of  a  reddish-pink  color. 

The  qualitative  examination  for  free  hydrochloric  acid  can  be 
made  with  this  paper  by  dipping  it  into  the  filtered  or  unfiltered 
gastric  contents.  If  free  hydrochloric  acid  is  present,  it  will  turn 
blue. 

Determination  of  Hydrochloric  Acid  Deficit. — Honigmann^ 
and  Von  Noorden^  determine  the  degree  of  hydrochloric  acid  insuifi- 
ciency  by  adding  a  decinormal  hydrochloric  acid  solution  to  the 
stomach  contents  until  free  hydrochloric  acid  can  be  detected  by 
Congo  paper  or  Giinzburg's  test. 

Ten  cc.  of  the  filtrate  are  placed  in  a  beaker  and  the  decinormal 
hydrochloric  acid  solution  allowed  to  flow  into  it  gradually,  the 
solution  being  well  mixed.  The  test  being  continued  until  after 
repeatedly  dipping  the  Congo  paper  into  it  it  shows  a  bluish  tinge. 

The  more  hydrochloric  acid  required  to  secure  the  reaction,  the 
*less  the  amount  of  combined  acid  in  the  filtrate. 

1  Berlin,  klin.  Wochenschr.,  1H93,  Nos.  15  and  16.  2  ibid.,  No.  19. 


Io8  DISEASES    OF   THE    STOMACH   AND   IXTESTIXES 

Or,  about  25  drops  of  Giinzburg's  solution  can  be  added  to  the 
filtrate,  and  then  titration  with  the  dilute  acid  follows  until  a  red 
mirror  appears  on  a  porcelain  dish  as  a  couple  of  drops  of  this  mix- 
ture are  evaporated  over  an  alcohol  lamp. 

We  know,  however,  that  the  average  amount  of  combined  hydro- 
chloric acid  is  25,  or  o.i  per  cent.,-  under  normal  conditions,  and 
Tbpfer's  method  of  testing  will  give  the  required  data. 

The  amount  of  pepton  and  propepton  qualitatively  are  an  indica- 
tion. When  there  is  no  biuret  reaction,  there  will  be  no  combined 
hydrochloric  acid. 

Other  Methods  of  Testing  the  Gastric  Secretion. — There  are 
several  ingenious  methods  for  testing  the  gastric  secretion  in  order 
to  obviate  the  unpleasant  procedure  of  aspiration,  or  because  some 
patients  absolutely  refuse  the  tube,  or  there  is  danger  incurred  from 
its  passage,  such  as  in  cases  of  aneurism,  angina,  severe  endocarditis, 
or  after  a  recent  hemorrhage  from  the  stomach  or  lungs,  or  in  the  very 
debilitated. 

Sahli's  Desmoid  Test} — This  consists  in  placing  methylene-blue 
or  iodoform  in  a  small  rubber  bag  and  tying  it  tightly  with  thin  raw 
catgut.  The  bag  is  swallowed  after  a  large  meal,  and  the  urine  is 
examined  for  methylene-blue,  or  the  saliva  for  iodin.  Methylene- 
blue  colors  the  urine  green  or  greenish  blue.  The  iodin  is  tested  for 
in  the  saUva  by  starch-paper  and  fuming  nitric  acid,  giving  a  bluish 
or  violet  color.  It  is  based  on  the  fact  that  raw  connective  tissue, 
including  catgut,  is,  according  to  Schmidt,-  digested  only  b}^  the 
gastric  juice  and  not  by  the  pancreas. 

The  reaction  occurs  in  health}'  persons  usually  six  to  eight  hours 
after  swallowing  the  bag.  If  it  takes  place  later,  or  not  at  all,  the 
secretory  function  is  insufficient.  An  early  reaction  shows  hyper- 
acidity, according  to  Kaliski. 

Einhorn,^  in  some  cases  of  achylia  gastrica  and  cancer,  has 
demonstrated  that  catgut  is  also  digested  in  the  bowel,  so  that  the 
method  is  unsuitable. 

2.  Gunzburg's  Method.^ — This  is  based  on  the  same  principle  as 
Sahli's.  The  patient  swallows  0.2  gm.  potassium  iodid,  enclosed  in 
a  small  rubber  bag,  which  is  tied  with  fibrin  threads. 

After  the  fibrin  is  digested,  the  potassium  iodid  is  set  free  and 
absorbed.  The  test  of  the  saliva  is  made  \vith  starch-paper  and  fuming 
nitric  acid,  giving  a  violet  or  bluish  color.  This  necessitates  frequent 
examinations  of  the  saliva,  and  the  bag  may  escape  and  the  fibrin 
be  digested  in  the  intestine.  The  objections  are  the  same  as  to 
Sahli's  test. 

3.  Spallanzani    and    Edinger's    Method.'^ — They    fasten    a    small 

1  Correspondenzblatt  fiir  Schweizer  Aerzte,  1905,  Xos.  8  and  9. 

2  Deutsch.  med.  Wochenschrift,  1899,  No.  49. 

^Journal  of  the  American  Medical  Association,  May  12,  1906. 

*  Deutsch.  med.  AVochenschr.,  1889,  No.  4. 

5  Deutsch.  Arch.  f.  klin.  Medizin,  vol.  xxviii,  1881. 


EXAMINATION    OF   THE    FUNCTIONS    OF    THE    STOMACH 


109 


sponge  to  a  silk  thread.  The  patient  swallows  this,  and  after  several 
minutes  it  is  withdrawn  and  the  contents  squeezed  out  and  examined. 
Some  of  the  contents  are  squeezed  out  during  removal,  and  secretions 
of  the  esophagus  and  pharynx  are  mixed  with  it. 

4.  Dunham's  Thread  Test} — The  patient  swallows  a  small  tassel 
of  test  thread,  colored  with  litmus,  Congo,  or  dimethylamido-azo- 
benzol,  attached  to  a  silk  thread  about  30  inches  long.  After  about 
five  minutes  it  is  withdrawn  and  the  color  reaction  noted.  There 
are  the  same  objections  as  to  the  previous  test. 

5.  Einhorn's  Stomach  Bucket? — This  consists  of  a  small  silver 
capsule,  open  at  the  top,  with  a  cross-piece  as  a  handle,  to  which 
a    silk    thread     is    attached. 

Several  sizes  can   be   secured 
(Figs.  65  and  66). 


Fig.   65. — Einhorn's   stomach   bucket, 
three  sizes. 


Fig.  66. — Stomach  bucket  set. 


The  bucket  is  moistened  in  warm  water  and  emptied.  It  is  then 
placed  on  the  root  of  the  tongue  and  swallowed  by  the  patient.  The 
vessel  should  remain  in  the  stomach  for  about  five  minutes.  It  is 
then  withdrawn  by  the  silk  thread. 

During  the  act  of  withdrawal,  if  resistance  is  felt,  the  patient  is 
told  to  swallow  and  the  bucket  is  then  readily  removed. 

If  there  are  mucus  and  saliva  in  the  patient's  mouth,  he  should 
first  gargle  with  plain  water  and  expectorate  the  mucus. 

The  test  breakfast  should  be  given  and  the  bucket  administered 
an  hour  later.  The  gastric  contents  are  poured  from  this  instrument 
into  a  small  beaker.  Tests  can  then  be  made  with  blue  litnms  and 
Congo  paper.     A  single  drop  can  be  tested  with  Giinzburg's  solution.- 

Einhorn  demonstrates  that  the  amount  of  hydrochloric  acid  can 
be  approximately  determined  by  diluting  i  drop  of  the  filtrate  with 
water,  until  Gunzburg's  reaction  begins  to  disappear  in  the  diluted 


1  New  York  University  Bulletin  of  the  Medical  .Sciences,    vol.    i,    No. 
178,  Oct.,  1901. 

2  Medical  Record,  July,  1890. 


4.    P- 


no  DISEASES    OF   THE    STOMACH   AND    IXTESTIXES 

fluid.  He  finds  that  normally  the  drop  can  be  diluted  up  to  eight 
or  ten  times  and  give  the  Gtinzburg's  reaction.  The  disappearance 
of  the  reaction  after  five  times  dilution  or  less  shows  subaciditv. 

The  presence  of  the  reaction  after  dilution  of  twelve  times  or  more 
shows  hyperacidity. 

Recently  he  has  employed  another  approximate  method  with 
a  strip  of  paper  saturated  with  0.5  per  cent,  dimethyl-amido-azo- 
benzol  solution  and  with  dilution.  If  the  paper  turns  red  after 
dilution  of  i  drop  of  filtrate  with  3  to  6  drops  of  water,  free  hydro- 
chloric acid  is  normal;  if  no  color  appears  after  3  drops  of  dilution, 
it  is  subacid;  and  if  red  appears  after  over  6  drops  dilution,  it  is 
hyperacid. 

If  rennet  is  present,  pepsin  is  also  present;  2  drops  of  filtrate 
added  to  2  cc.  of  milk  placed  at  blood  temperature  in  a  tube  in  warm 
water  will  curdle  in  ten  to  twenty  minutes  in  the  presence  of  rennet. 

I  employ  this  method  in  exceptional  cases,  when  the  stomach-tube 
cannot  be  passed.     It  is  preferable  to  aspirate. 

Gas  Fermentation. — The  presence  of  free  hydrochloric  acid 
does  not  prevent  the  development  of  gas.  It  ma}^  occur  in  a  soil 
that  is  non-acid,  together  with  lactic  acid  fermentation.  Stagnation 
is  the  chief  factor  favoring  fermentation.  A^arious  gases  may  be 
formed,  but  from  a  practical  point  of  view  the  determination  of  its 
occurrence,  quantity,  and  the  time  necessary  for  its  development 
are  sufiicient. 

The  unfiltered  gastric  contents  should  fill  a  tube  such  as  is 
emplo^'ed  for  the  determination  of  sugar  in  the  urine  (the  Fiebig 
tube).'  It  should  be  placed  in  an  incubator  at  37°  C.  (98.6°  F.), 
or  if  this  is  not  at  hand,  in  a  uniform  warm  place.  One  can  employ 
a  test-tube,  as  suggested  by  ^loritz,  closed  by  a  rubber  cork  through 
which  is  passed  a  bent  glass  tube.  The  test-tube  is  filled  with  gastric 
contents  and  then  closed  with  the  cork,  thus  forcing  some  of  them 
into  the  curved  tube  and  preventing  the  entrance  of  air.  The 
apparatus  is  inverted  in  a  beaker. 

As  at  times  the  sugar  may  already  be  destroyed  by  fermentation, 
it  is  well  to  prepare  a  control  tube  of  gastric  contents  to  which  a  small 
quantity  of  powdered  dextrose  has  been  added,  or  it  may  be  added 
at  once.  If  no  development  of  gas  is  noted  after  twenty-four  hours, 
the  tube  should  be  allowed  to  stand  for  three  or  four  days. 

Carbon  dioxid  mav  be  identified  bv  allowing  a  small  amount  of 
KOH  to  flow  through  a  pipet  to  the  bottom  of  the  gas  column. 
The  carbonic  acid  is  absorbed  by  it  and  the  fluid  moves  up  to  take 
the  place  of  the  absorbed  gas.  The  expressed  test  meal,  or  test 
breakfast,  or  vomitus  can  be  employed. 

If  fermentation  is  excessive,  one  can  assume  motor  insufficiency. 
If  rapid  fermentation  occurs  within  a  few  hours,  pyloric  stenosis 
should  be  suspected,  as  this  produces  the  most  severe  degree  of  motor 
insufficiency. 


EXAMINATION    OP    THE)    FUNCTIONS    OF    THE    STOMACH  III 

If  the  stomach  contains  a  large  amount  of  lactic  acid  and  no  free 
hydrochloric  acid,  carcinoma  of  the  pylorus  is  probably  the  cause 
of  this  stenosis. 

Gaseous  fermentation  is  usually  more  intense  in  cases  of  motor 
insufficiency  in  which  free  hydrochloric  acid  is  present.  It  can  occur, 
however,  in  any  form  of  stomach  disease  in  which  there  is  a  disturb- 
ance of  gastric  secretion.  Lactic  acid  fermentation  only  occurs 
markedly  in  subacid  conditions.  Alcohol,  various  hydrocarbons, 
and  sulphuretted  hydrogen  have  been  found  as  products  of  fermenta- 
tion.    Boas  finds  H2S  chiefly  in  benign  ectasia. 

Determination  of  the  Quantity  of  Chyme  Within  the  Stomach. 
— Usually  the  quantity  of  chyme  can  be  determined  by  emptying 
the  patient's  stomach  by  the  expression  method,  especially  with  the 
addition  of  the  aspirating  bulb  that  I  have  described. 

Air  can  be  forced  into  the  stomach  by  covering  the  free  end  of  the 
bulb  and  squeezing  the  latter.  If  no  bubbling  sound  is  heard,  the 
organ  may  be  considered  empty.  With  marked  dilatation  from  py- 
loric stenosis,  it  is  at  times  difficult  to  completely  empty  the  organ. 

Matthieu  and  Remond  suggest  the  following  method  of  deter- 
mining the  total  quantity: 

After  removal  of  the  contents,  a  funnel  is  attached  to  the  tube 
and  200  cc.  of  water  poured  into  the  stomach.  The  funnel  is  moved 
up  and  down  several  times,  and  the  patient  shakes  the  abdomen  so 
that  complete  mixture  of  the  water  and  contents  occurs.  They  are 
then  removed  by  a  combination  of  siphonage  and  expression. 

The  quantity  of  liquid  originally  contained  in  the  stomach  is 
equal  to  the  number  of  cubic  centimeters  of  water  poured  into  the 
stomach  multiplied  by  the  degree  of  acidity  of  the  second  portion 
removed,  divided  by  the  figure  resulting  by  deducting  the  degree  of 
acidity  of  the  second  portion  from  that  of  the  first  plus  the  portion 
previously  withdrawn. 

Examination  of  the  Vomit. — The  same  methods  that  are  em- 
ployed in  examination  after  the  test  meal,  apply  to  investigation  of 
the  vomitus.  The  information,  however,  is  not  as  positive,  as  the 
admixture  of  bile,  saliva,  etc.,  obscures  the  result.  Important 
information  is  secured,  but  the  physician  should  inspect  the  vomitus 
in  person. 

If  the  vomiting  consists  chiefly  of  food,  it  should  be  learned  when 
the  last  meal  was  taken  and  of  what  it  consisted.  If  coarse  morsels 
are  found  six  or  seven  hours  after  a  meal  the  conclusions  are  naturally 
different  than  if  they  were  found  directly  after  eating;  and  by  this 
means  we  can  often  determine  the  digestive  and  motor  powers  of 
the  patient. 

If  food  is  vomited  that  was  ingested  the  day  before,  marked  motor 
insufficiency  is  present. 

In  ulcer,  vomiting  usually  occurs  at  the  height  of  digestion.  In 
some  nervous  diseases  it  usually  takes  place  immediately  after  eating. 


112  DISEASES   OF   THE    STOMACH   AND    INTESTINES 

With  ectasia,  vomiting  occurs  late  in  digestion  and  often  in  great 
quantity. 

In  dilatation,  with  hypersecretion,  the  fluid  is  abundant,  and 
there  are  fine  remnants  of  amylaceous  material ;  while  with  carcinoma 
of  the  pylorus  undigested  morsels  of  meat  are  present.  In  the 
former  case  free  hydrochloric  acid  is  present,  and  Congo  paper  will 
turn  blue;  in  the  latter  case,  no  color  change  occurs. 

The  presence  of  blood  is  important,  and  its  appearance  depends 
on  the  presence  or  absence  of  hydrochloric  acid,  on  the  rapidity  with 
which  it  is  poured  forth,  and  on  the  length  of  time  it  has  remained 
in  the  stomach.  It  may,  therefore,  look  like  chocolate  brown, 
coffee-grounds,  or  fresh  blood. 

Mucus  is  also  readily  discovered.  Pus  is  rarely  found,  unless 
from  perforation  in  phlegmonous  gastritis,  or  from  some  neighboring 
focus  into  the  stomach,  or  unless  it  has  been  swallowed. 

During  violent  vomiting,  bile  is  frequently  in  evidence,  or  when 
vomiting  occurs  on  an  empty  stomach.  It  may  occur  with  pyloric 
stenosis,  when  the  opening  is  kept  slightly  patent.  With  persistent 
vomiting  of  bile  one  would  suspect  some  obstruction  of  the  duodenum, 
such  as  carcinoma,  torsion,  gall-stones,  etc. 

Parasites,  such  as  ascarides  or  the  oxyuris  vermicularis,  are 
occasionally  found  in  the  vomit,  and  very  rarely  a  piece  of  gastric 
tumor. 

Examination  of  the  Contents  of  the  Fasting  Stomach. — It 
may  be  necessary  to  investigate  the  contents  of  the  fasting  stomach, 
especially  when  disturbance  of  the  motor  function  is  present  or  when 
hypersecretion  is  suspected.  Under  normal  conditions  one  might 
expect  to  find  from  5  to  even  1 5  cc.  of  gastric  contents  in  the  normal 
stomach.     Anything  over  20  cc.  is  considered  pathologic. 

The  examination  should  be  made  in  all  cases  where  one  suspects 
an  abnormal  quantity  of  gastric  contents  will  be  found  in  the  morning 
after  fasting;  also  in  all  cases  of  suspected  ectasia  or  aton}'  of  the 
stomach. 

The  best  method  is  to  wash  the  stomach  thoroughly  the  night 
before,  both  in  the  sitting  and  reclining  posture,  and  then  administer 
a  test  supper.  The  contents  are  aspirated,  measured,  and  examined 
the  following  morning  before  breakfast.  The  chief  purpose  is  to 
test  the  motor  function  of  the  organ,  especially  to  determine  whether 
motor  insufficiency  of  a  high  degree  is  present. 

When  hypersecretion  is  suspected,  the  procedure  is  sUghtly 
different.  The  stomach  is  thoroughly  washed  at  about  10  p.  m.  and 
care  taken  that  all  the  water  is  removed.  No  food  or  drink  are 
allowed  thereafter,  and  in  the  morning  before  breakfast  the  contents 
are  aspirated  and  examined.  A  quantity  over  20  cc.  found  repeatedly 
I  would  consider  pathologic  (hypersecretion). 

When  there  is  permanent  regurgitation  of  bile  into  the  stomach, 
Riegel  has  shown  that  this  method  of  examining  is  important.     If 


EXAMINATION   OF    THE    FUNCTIONS    OF    THE    STOMACH  II 3 

bile  and  pancreatic  juice  enter  the  stomach,  digestive  processes  are 
arrested. 

Bile,  pancreatic,  and  probably  intestinal  juice  are  occasionally 
found  in  the  empty  stomach  (duodenal  juice,  Boas).  This  material 
is  grass  green  or  yellowish,  containing  bile  constituents,  and  converts 
starch  into  maltose  and  dextrose,  proteids  into  peptones,  and  splits 
fats.  If  it  is  aspirated  occasionally,  it  is  probably  not  significant; 
but  if  there  is  constant  regurgitation,  it  is  suggestive  of  obstruction 
in  the  duodenum. 

When  there  is  obstruction  to  the  flow  of  the  intestinal  contents, 
or  a  communication  between  the  stomach  and  intestine,  intestinal 
contents  are  found  in  the  stomach. 

ABNORMAL  CONSTITUENTS  OF  THE  STOMACH  CONTENTS 

Abnormal  products  which  are  of  importance  for  our  diagnosis 
are  quite  frequently  found  in  the  gastric  contents.  They  may  con- 
tain mucus,  blood,  bile,  intestinal  juice,  and  pus. 

Mucus  when  present  in  considerable  quantity  is  easily  recognized. 
It  generally  occupies  the  upper  part  of  the  fluid,  appearing  in  swollen 
glassy  lumps  or  in  flakes  and  shreds.  It  is  also  intimately  mixed 
with  the  food.  It  can  be  readily  lifted  with  a  glass  rod.  If  in  small 
amount,  a  few  drops  of  dilute  acetic  acid  are  added  and  it  will  be 
revealed  by  the  characteristic  precipitate. 

Bile  and  Intestinal  Juice. — Small  quantities  of  bile  and  intes- 
tinal juice  may  occasionally  be  met  with  normally.  In  the  para- 
graph on  "Examination  of  the  Contents  of  the  Stomach  after  Fasting" 
I  referred  to  the  presence  of  bile  and  intestinal  juice  and  that  their 
frequent  occurrence  is  due  either  to  relaxation  of  the  pylorus  or 
stenosis  of  the  duodenum  below  the  mouth  of  the  bile-duct.  Pure 
bile  is  golden  yellow,  but  green  if  mixed  with  gastric  juice.  I  believe 
that  too  often  the  diagnosis  is  made  by  simple  inspection.  Mould 
may  produce  a  greenish  color,  and  I  have  found  it  on  several  occa- 
sions. For  accuracy,  the  tests  should  be  made;  Gmelin's  for  bile- 
pigment  and  Pettenkofer's  for  bile-acids. 

Einhorn  suggests  the  following  for  the  intestinal  juice,  which  is 
recognized  by  its  ferments,  trypsin,  amylopsin,  and  steapsin: 

Trypsin. — Mix  the  filtrate  with  i  per  cent,  solution  of  sodium 
carbonate  until  the  reaction  is  decidedly  alkaline;  add  a  flake  of 
fibrin  and  keep  in  a  warm  place  for  several  hours.  Trypsin  will 
dissolve  the  fibrin. 

Amylopsin. — Starch  is  changed  into  maltose. 

Steapsin. — Add  i  drop  of  blue  litmus  tincture  and  a  few  cubic  cen- 
timeters of  the  neutralized  filtrate  to  a  small  portion  of  milk  and  keep 
at  blood  temperature.  Steapsin  changes  the  blue  color  and  the  milk 
becomes  slightly  reddish  from  decomposition  of  the  fat  into  fatty  g^cids. 

Blood. — Blood  in  large  quantities  is  easily  recognized,  as  is  fresh 
blood,  even  if  in  small  amounts. 
8 


114  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

Fresh  blood  mixed  with  gastric  contents  presents  a  reddish 
appearance,  while  old  blood  is  brownish  or  of  a  coffee-ground  color. 
It  may  even  appear  blackish.  When  the  blood  cannot  be  detected 
microscopically  and  gastric  hemorrhage  is  suspected,  occult  blood 
must  be  examined  for. 

It  is  advisable  to  make  the  same  examination  of  the  stool. 

I.  Benzidin  Blood  Test  for  Gastric  Contents  and  Stool. — This 
is  the  most  recent  test  devised  by  O.  and  R.  Adler.^  They  first 
applied  it  to  test  the  feces.  Schlesinger  and  Hoist"  advise  boiling 
the  gastric  filtrate  and  testing  in  the  same  manner  as  for  feces. 

Gastric  Contents. — Solution  i. — Knifepointful  of  benzidin  (Merck's) 
is  added  to  2  cc.  of  glacial  acetic  acid  and  allowed  to  stand  and 
dissolve. 

Solution  2. — Ten  to  12  drops  of  the  benzidin  solution  are  added 
to  2\  or  3  cc.  of  a  3  per  cent,  peroxid  of  hydrogen  solution. 

Three  or  4  drops  of  the  gastric  filtrate,  which  has  been  boiled  for 
about  half  a  minute,  are  added  to  Solution  2.  In  the  presence  of 
blood,  a  green  or  blue  color  results  in  from  a  few  seconds  to  a  minute. 

Stool. — The  stool  should  also  be  examined.  A  small  piece  of  feces 
about  the  size  of  a  pea  is  mixed  with  2  cc.  of  water  and  boiled  in  a 
test-tube  closed  with  cotton  for  half  a  minute ;  3  or  4  drops  of  the 
boiled  fecal  solution  are  added  to  Solution  2.  A  green  or  blue  color 
results  if  blood  be  present. 

Benzidin  .Test  Paper. — Einhorn^  has  devised  a  benzidin  testing 
paper  as  follows : 

Take  a  saturated  solution  of  benzidin  and  glacial  acetic  acid; 
moisten  filter-paper  therein  and  dry  it.  Both  in  preparing  the  paper 
and  making  the  test  avoid  contact  with  the  fingers,  as  a  drop  of 
perspiration  causes  the  reaction.  When  handhng  the  paper  employ 
ivory-tipped  forceps  or  protect  the  hand  by  a  towel. 

Method. — Gastric  Contents. — A  piece  of  benzidin  paper  is  first 
immersed  in  the  gastric  filtrate,  and  then  a  few  drops  of  hydrogen 
peroxid  are  added.  The  paper  is  then  placed  on  a  piece  of  white 
porcelain  and  examined  for  the  development  of  a  blue  color.  If 
blood  is  present,  a  blue  or  green  color  occurs  in  a  few  seconds  to  a 
minute.  Einhorn  shows  that  if  we  wait  longer  periods,  other  sub- 
stances may  cause  the  reaction,  also  in  time  the  paper  moistened 
with  peroxid  will  become  blue. 

Feces. — In  testing  for  occult  feces  with  the  paper,  a  small  piece 
the  size  of  a  pea  is  rubbed  up  with  2  cc.  of  water,  the  benzidin  paper 
immersed  therein,  a  drop  of  hydrogen  peroxid  added,  and  the  blue 
color  then  examined  for. 

The  benzidin  paper  Einhorn  recommends  as  a  preliminary,  and 
if  there  is  immediately  a  strong  reaction  or  none  at  all,  he  regards  the 

1  Zeitschr.  fiir  physiol.  Chemie,  Bd.  41,  Heft  i  and  2,  p.  59. 

2  Deutsch.  med  Wochenschr.,  1906,  No.  36,  p.  1444. 
^  "  A  New  Blood  Test,"  Med.  Record,  June  8,  1907. 


EXAMINATION    OF   THE    FUNCTIONS    OF   THE    STOMACH  115^ 

result  as  reliable.  If  at  the  end  of  a  minute  only  a  trace  of  reaction 
occurs,  then  the  aloin-ether  extract  method  may  be  employed  as  a 
check. 

In  the  fecal  examination,  ether  extract  of  feces,  as  employed  in 
the  aloin  test,  makes  the  benzidin  test  more  reliable. 

In  examination  of  the  gastric  contents  no  meat  products  or  iron 
preparations  should  be  taken  for  at  least  twenty -four  hours  before  the 
test,  and  in  testing  the  stool  tJie  same  rule  must  be  osbervcd;  but,  prefer- 
ably, for  a  longer  period  if  possible,  at  least  two  to  three  days  as  a 
precautionary  measure. 

2.  Weber's  Modification  of  Van  Deen's  Test  for  Occult 
Blood. — Dilute  the  stomach  contents  or,  preferably,  the  filtrate  thereof 
with  I  volume  of  glacial  acetic  acid,  and  extract  with  about  10  cc. 
of  ef her.  A  few  cubic  centimeters  of  this  acid  ether  extract  are  mixed 
with  10  drops  of  tincture  of  guaiac  and  20  to  30  drops  of  ozonized  oil 
of  turpentine  (old  turpentine  exposed  to  air). 

If  blood  is  present,  the  mixture  turns  a  blue  or  blue  violet;  if 
absent,  it  turns  a  reddish  brown  with  a  green  tinge.  The  reaction  is 
more  distinct  if  a  little  water  is  added  and  the  blue  pigment  extracted 
with  chloroform. 

The  Stool. — The  test  for  occult  blood  is  as  follows: 

Treat  5  cc.  of  feces  with  20  cc.  of  ether ;  the  latter  is  then  poured 
off;  2  cc.  of  glacial  acetic  acid  are  added  to  the  feces  and  thoroughly 
stirred.  This  mixture  is  again  treated  with  about  10  cc.  of  ether  and 
allowed  to  separate. 

To  2  cc.  of  the  etherized  extract  add  2  to  3  drops  of  a  fresh  tinc- 
ture of  guaiac.  Then  add  20  to  30  drops  of  ozonized  oil  of  turpentine, 
or  pure  hydrogen  peroxid,  and  shake  well.  If  blood  be  present,, 
there  appears  a  blue  or  blue-violet  color. 

Meat  and  iron  preparations  should  be  avoided  for  from  twenty- 
four  to  seventy-two  hours  before  these  tests. 

3.  Klunge's  Aloin  Test. — Feces. — In  this  test  freshly  prepared 
aloin  is  employed.  Dissolve  as  much  aloin  as  can  be  placed  on  the 
tip  of  a  knife  blade  in  10  cc.  of  70  per  cent,  alcohol;  add  2  cc.  of  the 
aloin  solution  to  2  cc.  of  the  ethereal  extract  of  feces,  prepared  as 
above,  and  then  the  oil  of  turpentine  or  peroxid  of  hydrogen,  as 
described.    A  cherry-red  color  appears  in  the  fluid  if  blood  be  present. 

Gastric  Contents. — Ethereal  extract  of  the  filtrate  is  prepared  as 
in  Weber's  test.     Rest  of  test  is  same  as  aloin  test  of  feces. 

Einhorn  at  times  employs  aloin  paper  prepared  with  filter-paper 
saturated  with  a  solution  of  aloin  in  70  per  cent,  alcohol,  the  paper 
being  then  dried  for  future  use.    1  prefer  the  benzidin  or  Weber's  test. 

The  spectroscopic  test,  hemin  test,  etc.,  have  been  suggested, 
but  the  ones  described  are  the  most  practical. 

Pus  is  seldom  found  in  the  gastric  contents  and  is  recognized 
readily  under  the  microscope.  Excluding  ingested  pus  and  phleg- 
monous gastritis,  pus  shows  ulceration  of  the  gastric  mucosa. 


Ii6 


DISEASES   OF  THE   STOMACH  AND   INTESTINES 


Fig.  67. — Fasting  gastric  juice  con- 
taining mucus,  snail  forms,  epithelial 
cells,  and  amorphous  material. 


MICROSCOPIC  EXAMINATION   OF   THE   GASTRIC  CONTENTS 

The  relative  value  of  the  microscopic  examination  of  the  gastric 
contents  after  the  test  meal,  of  the  vomitus,  and  of  the  fasting 
stomach  contents,  as  compared  with  gastric  analysis,  is  still  a  matter 

of  dispute. 

Some  of  the  ardent  advo- 
cates of  the  microscope  go  so 
far  as  to  claim  that  their 
method  is  alone  necessary.  Un- 
doubtedly, in  many  cases  the 
clinical  symptoms,  gastric  anal- 
ysis, the  test  of  the  motor  func- 
tion, and  macroscopic  inspection 
of  the  contents  afford  sufficient 
information  for  diagnosis.  I  do 
not  wish,  however,  to  depreciate 
the  value  of  the  microscope, 
as  in  some  cases  it  is  of  funda- 
mental importance. 

Gastric  Secretion. — When 
fasting,  the  gastric  secretion 
shows  normally  under  the  micro- 
scope epithelial  cells,  cell  nuclei,  some  mucus,  amorphous  material, 
and  micro-organisms.  Jaworski^  describes  spiral  or  snail-like  bodies 
in  cases  of  hvperchlorhydria,  but  Boas  believes  they  are  quite 
common  and  that  they  are 
developed  from  the  mucus 
by  the  action  of  the  gastric 
juice  (Fig.  67).  Einhorn 
has  found  them  in  patients 
with  normal  secretion. 

Mucus.  —  Mucus  from 
the  bronchi  and  lungs  is 
characterized  by  the  pres- 
ence of  alveolar  cells  and 
myelin  drops;  while  the  oc- 
currence of  a  great  many 
columnar  epithelial  cells  is 
evidence  of  the  origin  from 
the  gastric  mucous  mem- 
brane. 

In     doubtful     cases    the 
microscope  will  thus  deter- 
mine the  origin  of  the  mucus,  either  by  examination  of  the  fasting 
contents  or  after  a  test  meal.     The  clinical  symptoms  and  macro- 


Fig.  68. — a,  Nuclei  of  leukocytes;  b,  spiral 
bodies;  c,  nuclei  of  epithelial  cells;  d,  striated 
mucus. 


1  Miinch.  med.  Wochenschr.,  1887,  No.  30. 


EXAMINATION    OF    THE    FUNCTIONS    OF   THE    STOMACH  II 7 

scopic  appearance  of  the  contents,  as  described  under  chronic  gas- 
tritis, will,  however,  generally  give  sufficient  information. 

Paul  Cohnheim  holds  that  the  presence  of  free  nuclei  of  leu- 
koc^iies  and  epithelial  cells  is  a  positive  evidence  of  hydrochloric 
acid  and  pepsin  (Fig.  68). 

I  believe  that  gastric  analysis  is  much  preferable  for  such  deter- 
mination. Importance  has  been  attached  to  the  presence  of  two 
varieties  of  infusoria,  the  Trichomonas  hominis  and  Megastoma 
entericum,  notably  by  Cohnheim  (Fig.  69).  He  beHeves  that 
their  .presence  is  pathognomonic  of  carcinoma,  not  affecting  the  motility 
of  the  stomach.     Ameb^  are  often  associated  with  them. 

The  development  of  these  infusoria  requires  the  absence  of  hydro- 
chloric acid,  an  alkaline  medium,  and  the  existence  of  deep  folds  in  the 
mucosa.  Previous  to  aspiration,  the  stomach-tube  and  receptacle 
should  be  warm^ed. 


Fig.  69. — a,  Pus  cells;  b,  trichomonas;  c,  megastoma;  d,  pavement  epithelium. 

To  differentiate  between  cancer  and  achylia  gastrica,  in  the 
suspected  cases,  with  emaciation,  gastric  distress,  and  achylia, 
special  examination  for  these  infusoria  is  advocated  by  Cohnheim. 
The  presence  of  pus,'  especially  if  associated  with  blood  in  the  non- 
fetid  gastric  contents,  he  also  believes  aids  in  the  early  diagnosis 
before  the  tumor  is  palpable.  Phlegmonous  gastritis  and  the 
ingestion  of  pus  from  above  must  be  excluded. 

Sarcinge  and  the  Boas-Oppler  bacillus  can  be  examined  for,  both 
in  the  fasting  stomach  and  after  the  test  meal.  The  same  is  true 
as  regards  epithelial  cells  and  pieces  of  the  gastric  mucosa.  I  will 
refer  to  them  shortly. 

Gastric  Contents. — The  microscopic  examination  of  the  gastric 
contents  after  the  test  breakfast  or  dinner  shows,  under  normal 
conditions,  a  few  starch  granules,  many  of  which  no  longer  appear  in 

^Microscopic  pus  in  the  gastric  contents  shows  ulceration,  not  necessarily 
malignant  in  type. 


ii8 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


Spiral  form.  The  muscular  fibers  do  not  show  their  diagonal 
stripes;  globules  of  fat,  plant-cells,  and  micro-organisms  are  present 
in  small  numbers. 

Many  unchanged  starch  granules  are  found  in  hyperchlorhydria 
and  h3'persecretion,  and  the  muscle-fibers  are  well  digested;  while 
with  hypochlorhydria  (deficient  secretion)  unchanged  muscle-fibers 
are  present.  The  granules  of  starch  are  brought  out  clearly  by  the 
addition  of  one  drop  of  tincture  of  iodin,  giving  a  blue  reaction.  The 
microscopic  findings  are  here  confirmatory  of  macroscopic  inspection. 

The  varieties  of  micro-organisms  have  been  thoroughly  studied 
by  DeBary\  Nencki,-  Boas,^  and  others.  It  has  been  demonstrated 
that  they  may  be  present  even  in  hyperchlorhydria,  showing  that 
the  hydrochloric  acid  does  not  always  prevent  fermentation. 

J.  Kaufmann^  has  described  a  case  of  hyperchlorhydria  in  which 
the  motor  function  of  the  stomach  was  not  markedly  disturbed,  but 


Fig.  70. — Benign  ectasia.  Yeast-cells  and  sarcinae  are  prominent:  a,  Muscle- 
fiber;  b,  plant-cells;  c,  sarcinae;  d,  starch  granules;  e,  degenerated  sarcin^;  /, 
yeast-cells;  g,  fat  crystals. 

which  showed  fermentative  processes.  He  isolated  eight  varieties 
of  micro-organisms  in  a  specimen  of  the  gastric  contents. 

Boas  has  also  described  the  development  of  sulphuretted  hydrogen 
in  a  case  of  hyperchlorhydria.  In  general,  we  may  say  that  fer- 
meniation  develops  in  cases  when  the  motility  of  the  stomach  is  reduced. 

Minkowski'  has  shown  that  if  free  hydrochloric  acid  be  abundant, 
yeast  and  thread  fungi  may  be  found;  while  if  it  is  absent,  numerous 
mould  organisms  are  present.  This  last  corresponds  to  the  findings 
of  A.  Rose  and  myself. 

1  Arch.  f.  Exper.  Path,  und  Therap.,  Bd.  20,  p.  243.    . 

2  Archiv.  f.  Exper.  Patholog.,  Bd.  28. 
^Deutsch.  med.  Wochenschr.,  1892. 

■*  Berlin,  klin.  Wochenschr.,  1895,  No.  6. 

^  See  Naunyn,  Mittheilungen  aus  der  medicin.  Klinik  zu  Konigsberg,  Leipsic, 


e;xamination  of  the  functions  of  the  stomach 


119 


Yeast. — A  few  isolated  yeast-cells  are  found  in  the  normal 
stomach.  In  ectasia  or  atony  of  marked  degree  the  yeast-cells  are 
numerous,  arranged  in  colonies,  and  are  in  active  process  of  germina- 
tion (Fig.  70). 

Sarcinae. — These  occur  usually  in  cubes  or  bales,  and  are  only 
pathologic  if  present  in  large  numbers,  as  in  benign  ectasia  or  atony 
(Fig.  70),  in  the  presence  of  hydrochloric  acid. 

They  are  rare  in  ectasia  from  cancer,  and,  if  present,  occur  usually 
in  cancer  developed  on  an  ulcer.  Their  presence  in  large  numbers 
is  an  aid  to  diagnosis. 

Boas-Oppler  Bacilli. — They  are  unusually  long,  non-motile 
bacteria,  and  are  characterized  by  their  large  size  and  end-to-end 
arrangement  (Fig.  71). 

They  must  be  differentiated  from  the  Leptothrix  buccahs,  by 
Gram's  solution,  with  which  they  stain  brown,  the  Leptothrix,  blue. 
Kaufmann's^  investigations  prove  the  Boas-Oppler  bacillus  has  the 

i? 


Fig.  71. — a,  Boas-Oppler  bacilli;  b,  leptothrix;  c,  potato-cell;  d,  yeast-cells. 

power  of  generating  lactic  acid  from  different  sugars.  Stagnation 
with  lactic  acid  fermentation  is  not  specific  of  pyloric  carcinoma,  but 
depends  on  the  absence  of  hydrochloric  acid  and  the  presence  of 
stagnation.     These  conditions  exist  in  stenotic  gastritis. 

These  bacilli  have  been  found  occasionally  in  stomach  contents 
that  contain  free  hydrochloric  acid  (Rosenheim).  Kaufmann  has 
demonstrated  them  in  19  out  of  20  cases  of  carcinoma. 

The  presence  of  these  bacilli,  with  pronounced  lactic  acid  fer- 
mentation and  taken  in  connection  with  clinical  symptoms,  is  very 
significant. 

Epithelial  Cells,  Particles  of  Timiors,  and  Fragments  of 
Gastric  Mucosa. — Single  cells  cannot  be  diagnosed  as  cancer  cells, 
but  cell-nests  nlust  be  found.     These  are  rare. 

1  Wiener  klin.  Wochenschr.,  1895,  No.  8. 


I20 


DISEASES    OF   THE    STOMACH    AND   INTESTINES 


Occasionally  after  aspiration  of  the  fasting  stomach,  or  test  meal, 
or  after  lavage,  or  in  the  vomitus,  small  particles  of  tissue  may  be 
found,  which  on  staining  may  reveal  the  nature  of  a  tumor. 

Hemmeter  recommends  in  suspected  cases,  first,  thorough  lavage 
and  rectal  feeding  for  a  day;  then,  passing  the  tube,  moving  it  about 
actively,  and  subsequent  aspiration  of  the  fasting  stomach.  This 
is  to  be  followed  bv  lavage.  All  tissue  fragments  are  to  be  examined. 
Einhorn  finds,  especially  after  lavage,  or  at  times  after  aspiration, 
small  pieces  of  mucous  membrane  which  he  stains  and  examines. 
Some  point  to  erosions,  others  to  other  affections.  The  fragment 
may  be  normal  mucosa,  or  there  may  be  proliferation  of  the  connective 
tissue,  or  of  the  glands,  or  atrophy  (partial  or  complete),  or  vacuoliza- 
tion. These  conditions  are  illustrated  in  their  appropriate  chapters. 
A  positive  judgment  cannot  be  given  from  this  examination,  as 
only  a  small  area  may  be  actually  involved  and  no  changes  obser^^^ed 
in  the  gastric  secretion.     On  the  other  hand,  a  bit  of  normal  mucosa 

may  be  aspirated  from  a  dis- 
. eased  organ. 

Mould.  —  Mould  in  the 
stomach  has  been  little  referred 
to  in  literature  as  a  pathologic 
condition  except  by  Talma, 
A.  Rose,  Naunyn,  Einhorn,^ 
and  Knapp.^  In  an  article  on 
"Dilatation  of  the  Stomach"^ 
I  have  already  referred  to  it. 

Einhorn  has  found  it  in 
the  wash-water  of  the  empty 
stomach,  as  blackish-gray  or 
brownish-green  flakes  of  varying 
number;  while  Knapp  describes 
it  as  coloring  the  chyme  a  yel- 
lowish green  or  dark  red,  and 
states  that  it  has  been  mistaken  respectively  for  bile  or  blood  from  its 
macroscopic  appearance.  He  emphasizes  the  necessity  for  appro- 
priate tests  for  bile  and  blood,  and  not  the  diagnosis  from  appear- 
ances. I  can  substantiate  this  in  one  case  at  least,  in  which  the 
reddish-brown  material  proved   to  be  mould. 

The  mould  flocculi  consist  of  clusters  of  spores  and  mycelia, 
sometimes  mixed  with  mucus  and  epithelial  cells.  Crystals  are  also 
found,  which  Knapp  considers  to  be  segments  of  mould  filaments. 

The  mould  generally  found  has  been  identified  by  E.  K.  Dunham 
as  the  penicillium  glaucum,  though  Knapp  reports  in  addition  the 
oidium  albicans  and  the  aspergillus  groups.     These  fungi  probably 

^  Medical  Record,  June  6,  1900. 

2  Organacidia  Gastrica,  Sept.  6,  1902. 

^Medical  News,  Aug.  16,  1904. 


Fig.  72. 


-Green  mould  follicle,  mycelia, 
spores,  and  crystals. 


EXAMINATION    OF"   THE    FUNCTIONS    OF   THE    STOMACH  121 

adhere  quite  closely  to  the  mucosa  and  may  involve  considerable 
areas  (Fig.  72). 

Einhorn  reports  mould  formation  in  hyperchlorhydria,  in  some 
cases  attended  with  hypersecretion,  and  also  in  gastralgia  with  normal 
or  reduced  gastric  secretion. 

Knapp  holds  that  the  presence  of  organic  acids  in  the  stomach 
have  a  decided  bearing,  and  that  succinic  acid  and  mould  go  hand 
in  hand,  the  presence  of  the  former  being  conclusive.  His  test  for 
succinic  acid  is  as  follows: 

Extract  i  cc.  of  filtered  chyme,  with  4  cc.  of  ether,  and  float  this 
extract  on  a  solution  of  ferric  chlorid  (i  drop  of  a  10  per  cent,  ferric 
chlorid  to  2  cc.  of  distilled  water)  in  a  narrow  test-tube.  At  the  line 
of  junction  is  a  dark  mahogany-red  ring.  He  further  describes 
symptoms  in  many  respects  resembling  severe  hyperchlorh3-dria 
with  spasm  of  the  pylorus,  and  believes  the  condition  influenced  by 
saccharine  material  in  the  chyme. 

In  the  experience  of  A.  Rose  and  the  author,  diminished  motility 
of  the  stomach  is  a  marked  factor  in  favoring  the  growth  of  mould. 
I  have  found  it  in  cases  of  atonic  ectasia,  producing  many  of  the 
symptoms  of  chronic  gastritis,  and  again  in  benign  stenosis  with 
hypersecretion.     The  subject  requires  still  further  investigation. 

Rose  finds  the  administration  of  TTLj  (0.059  cc.)  doses  of  beech  wood 
creosote  or  carbonate  of  creosote  gr.  v  (0.3)  t.  i.  d.  of  value,  and 
lavage  is,  of  course,  indicated,  preferably  with  warm  water — i  liter, 
followed  by  lavage  with  nitrate  of  silver  i :  2000,  or  spraying  the 
stomach  with  the  latter,  as  suggested  by  Einhorn. 

The  general  treatment  should  be  according  to  the  other  conditions 
present. 

DETERMINATION  OF  THE  ABSORPTIVE  FUNCTION  OF  THE 

STOMACH 

The  absorptive  function  of  the  stomach  is  usually  tested  by  the 
method  of  Penzoldt  and  Faber,  as  follows:  0.2  of  potassium  iodid 
is  administered  in  a  gelatin  capsule,  and  the  saHva  or  urine  examined 
every  minute  or  two  with  starch-paper  and  fuming  nitric  acid. 
The  strip  of  paper  is  moistened  with  saliva  or  urine  and  then  touched 
with  a  drop  of  the  acid.  A  violet  or  blue  color  is  the  reaction.  It 
takes  six  and  one-half  to  fifteen  minutes  before  the  reaction  appears 
in  normal  conditions.     In  pathologic  cases  it  is  retarded. 

The  test  should  be  made  on  an  empty  stomach,  as  with  the  full 
organ  it  is  retarded.  It  is  self-evident  that  the  gastric  digestion  of 
proteids — and  hence  their  absorption — is  delayed  in  cases  of  sub- 
acidity  or  anacidity,  while  these  conditions  are  not  so  important 
for  the  digestion  of  carbohydrates. 

In  some  cases  the  absorption  of  iodid  is  normal,  though  we  hnow 
proteid  digestion  is  interfered  with,  so  that  I  do  not  consider  the  test 
in  every  case  reliable.     Hershell  gives  a  capsule  containing  2  deci- 


122  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

grams  of  powdered  rhubarb.  Under  normal  conditions  the  urine 
gives  a  red  color  with  liquor  potassae.  They  are,  however,  the  best 
tests  so  far  known. 

Motor  Functions  of  the  Stomach. — By  this  we  mean  the 
peristaltic  action  of  the  stomach  which  expels  its  contents  into  the 
intestine.  The  impairment  of  the  motor  power  is  fully  as  and  in 
many  cases  more  important  than  damage  to  the  secretory  functions. 

The  best  method  of  testing  the  motor  power  is  by  the  test  meal. 
Leube's  is  the  oldest  method.  He  administered  a  plate  of  soup,  a 
beefsteak,  and  a  roll.  If  the  stomach  was  found  empty  seven  hours 
later  and  nothing  could  be  washed  out,  it  indicated  that  its  motor 
power  is  sufficiently  active.  If  the  food  remains  in  the  stomach 
longer,  the  motor  power  is  reduced. 

We  must  remember  that  in  pyloric  stenosis  the  motor  power 
may  be  reallv  increased  in  endeavoring  to  overcome  the  obstacle, 
but  that  food  remains  in  the  stomach  for  an  abnormal  length  of  time ; 
strictly  speaking,  it  is  a  relative  motor  insufficiency.  If  five  hours 
after  a  test  meal,  a  small  amount  of  chyme  is  aspirated,  the  motor 
power  is  good.  If  large  quantities  are  found  six  hours  after  the 
meal  the  motor  function  is  absolutely  (or  if  stenosis,  relatively) 
decreased.  Greater  degrees  of  insufficiency  may  be  present.  For 
example,  lavage  is  performed  and  a  test  supper  administered,  say, 
at  12  P.M.  and  the  contents  aspirated  seven  or  eight  hours  later. 
In  one  case  there  may  be  a  small  quantity  of  food  remaining,  and 
in  another  case  a  large  amount;  while  in  another,  none.  I  have 
found  chopped  spinach,  a  few  raisins,  or  a  piece  of  fig  an  addition  to 
the  test,  as  they  are  readily  recognized.     Boiled  rice  can  be  added. 

Boas  recommends  cold  meat  with  rolls  and  butter  and  a  large 
cup  of  tea. 

It  may  be  more  convenient  to  follow  the  same  procedure,  but  give 
the  meal  at  lunch  time.  Some  employ  the  test  breakfast.  Two 
hours  later  the  stomach  shotdd  he  empty.  If  loo  cc.  or  more  are  found 
at  the  end  of  an  hour,  or  varying  quantities  at  the  end  of  two  hours, 
it  shows  different  degrees  of  motor  insufficiency.  The  test  meal  is 
more  accurate.  I  sometimes  administer  a  test  supper  and  aspirate 
in  the  morning  to  test  the  motor  function,  following  immediately 
with  the  test  breakfast  to  examine  the  secretory  function. 

Salol  Test  (Ewald  and  Siever's  Method). — Salol  is  not  decomposed 
in  the  stomach,  but  in  the  alkaline  medium  of  the  intestine.  Here 
it  is  split  up,  and  the  salicylic  acid  is  absorbed  and  eliminated  in  the 
urine  as  salicyluric  acid.  The  latter  is  recognized  by  testing  the 
urine  with  neutral  ferric  chlorid  solution,  which  gives  a  violet  color 
with  this  acid. 

The  patient  takes  salol  i.o  (gr.  15)  in  two  gelatin  capsules  half 
an  hour  after  a  fight  meal.  The  bladder  is  first  emptied.  Thereafter 
he  urinates  every  half  hour  for  about  two  hours,  and  the  different 
specimens  of  urine  are  tested  with  the  iron  solution.     Under  normal 


EXAMINATION    OF   THE    FUNCTIONS    OF    THE    STOMACH  1 23 

conditions  the  reaction  appears  in  from  thirty  to  seventy-five  minutes. 
In  retarded  motiUty,  it  takes  two  hours  or  more. 

Ewald  treats  the  urine  with  ether  and  examines  the  ethereal 
residue ;  while  Einhorn  moistens  a  piece  of  filter-paper  with  the  urine 
and  touches  the  middle  of  it  with  the  iron  solution. 

Huber  suggests  to  determine  the  time  required  for  the  complete 
disappearance  of  the  reaction  in  the  urine.  The  longer  the  time 
required  for  the  salol  to  be  absorbed  and  entirely  eliminated  through 
the  urine,  the  longer  it  has  remained  within  the  stomach.  He  found 
that  normally  the  excretion  of  the  salicyluric  acid  after  salol  was 
administered  lasted  twenty-four  hours;  in  patients  with  diminished 
motor  function  it  lasted  forty-eight  hours  or  more. 

lodipin  Test. — lodipin  is  decomposed  in  the  intestine.  Heichel- 
heim  gives  i.6.gm.  iodipin  in  gelatin  capsules  at  breakfast.  The 
saliva  is  then  examined  every  fifteen  minutes  for  iodin  by  starch- 
paper  and  fuming  nitric  acid.  In  normal  cases  the  reaction  appears 
within  an  hour, 

Klemperer's  Oil  Test. — Oil  is  not  absorbed  in  the  stomach. 
After  washing  the  stomach,  100  cc.  of  pure  olive  oil  are  poured  into 
the  empty  organ.  Two  hours  later  the  stomach  is  thoroughly 
aspirated.  The  difference  between  the  original  quantity  of  oil  and 
that  withdrawn  indicates  the  condition  of  the  motor  function. 
Normally  at  this  time  only  20  to  40  cc.  of  oil  should  be  aspirated. 

Einhorn's  G  a  str  ogr  a  ph. —^mhom  has  invented  a  deglutible  ball, 
arranged  wdth  an  electric  circuit,  so  that  the  movements  which  mix 
and  break  up  the  food  can  be  registered. 

Hemmeter-Moritz  Method. — This  method  has  been  independently 
employed  by  Hemmeter  and  Moritz. 

A  thin  deglutible  bag  is  attached  to  an  esophageal  tube.  The 
bag  is  then  blown  up  and  connected  with  a  tambour  on  the  Ludwig 
kymograph,  which  registers  all  the  movements  with  a  pen.  A 
pneumograph  is  tied  about  the  chest  to  record  the  respiratory 
movements  as  a  basis  of  comparison.  The  muscular  contractions 
of  the  stomach  are  demonstrated  on  the  record  as  independent  of  the 
respiration. 

These  instruments  are  of  interest  scientifically,  but  their  practical 
value  has  not  been  demonstrated. 


CHAPTER  VII 
DIET 

The  study  of  nutrition,  both  in  health  and  disease,  is  important, 
but  it  will  only  be  possible  to  enunciate  the  general  principles. 

There  are  three  groups  of  food  stuffs — proteids,  carbohydrates, 
and  fats — procured  from  the  animal  and  vegetable  kingdoms,  which 
in  combination  furnish  the  most  suitable  form  of  nourishment. 
Climatic  conditions  and  environment  have  an  influence  on  the 
requirements  for  nutrition.  In  extremely  cold  climates  the  Esqui- 
maux have  lived  for  many  generations  on  nearly  an  exclusively 
nitrogenous  diet,  in  which  fat,  which  produces  the  greatest  number 
of  heat  units,  predominates.  In  hot  regions  many  of  the  races  live 
principally  on  a  non-nitrogenous  diet.  We  also  know  that  vege- 
tarians live  and  thrive  on  carbohydrates. 

A  mixed  diet  is  the  most  suitable  form  of  nourishment. 

DIET  IN  HEALTH 

Voit  has  emphasized  the  fact  that  the  smallest  amount  of  proteid, 
with  non -nitrogenous  food  added,  that  will  keep  the  body  in  con- 
tinual vigor  is  the  ideal  diet.  He  holds  that  a  healthy  adult  of  aver- 
age weight  should  ingest  loo  gm.  of  albumin,  50  gm.  of  fat,  and 
450  gm.  of  carbohydrate  in  twenty-four  hours;  others  place  the 
requirement  for  proteid  as  considerably  higher.  A  small  proportion 
of  the  food  serves  the  purpose  of  reconstructing  the  tissue  waste, 
while  the  major  part  is  used  for  generating  the  heat  required  for  the 
maintenance  of  life.  It  is,  therefore,  customary  to  speak  of  the 
necessary  amount  of  heat  units  during  the  twenty-four  hours  instead 
of  the  quantity  of  food. 

A  calorie  (or  heat  unit)  may  be  defined  as  the  amount  of  heat 

required   to   raise  i   gram  of  water   i  °  C.     This  is  a  small  calorie. 

A  large  calorie  is  the  amount  necessary  to  raise  i  kilogram  of  water 

1°  C.     Hence  a  large  calorie  equals  1000  small  calories. 

I  gm.  carbohydrate  yields  4.1  large   calories. 

I  gm.  fat  "     9.3      " 

I  gm.  proteid  "     4.1       "  " 

In  order  to  calculate  the  calorie  value  of  any  kind  of  food,  the  num- 
ber of  grams  of  albumin  that  are  contained  in  it  are  multiplied  by 
4. 1 ;  the  grams  of  carbohydrate  b}^  4.  i ;  the  grams  of  fat  by  9.3.  These 
are  added  together  and  give  the  total  calorie  value  of  the  food. 
For  example: 

100  gm.  albumin  X  4.1  =     410  calories. 

50    "     fat  X  9.3  =     465      " 

450    "     carbohydrate  X  4.1  =  1845      " 

2720  total  calories. 
124 


DIET  125 

The  calorie  value  of  vegetable  proteid  is  slightly  less  than  that  of 
animal  proteid;  50  gm.  of  fat  about  equal  113  gm.  of  starch  in  calorie 
value. 

Riegel  holds  that  a  human  being  at  rest  demands  about  35 
calories  per  kilogram  of  his  body  weight,  and  a  person  performing 
light  work  about  40  calories  per  kilo.  From  this  estimate,  the 
calorie  value  of  the  food  of  an  individual  weighing  50  kilos  is  from 
1750  to  2000  calories.  The  weight  of  the  patient  must,  therefore, 
be  known  in  order  to  select  the  correct  amount  of  nourishment. 

Rubner  states  that  different  articles  of  food  can  replace  each 
other  according  to  their  calorie  value,  and  that  it  is  immaterial  in 
what  form  the  calories  are  introduced  into  the  organism.  This 
may  be  taken  advantage  of  temporarily  in  certain  pathologic  condi- 
tions when  it  is  necessary  to  limit  some  special  variety  of  food,  such 
as  the  carbohydrates.  On  the  other  hand,  a  certain  amount  of 
proteid  is  necessary  for  the  organism,  while  unquestionable  damage 
can  be  done  by  excess  in  this  direction. 

The  results  of  scientific  study  are  opposed  to  the  prevailing 
dietary  standards,  especially  in  regard  to  proteid  foods.  It  is  true 
that  no  other  form  of  food  can  take  the  place  of  proteids,  for  a  certain 
quantity  is  needed  each  day  to  replace  the  loss  of  tissue  material 
broken  down,  and  our  choice  of  the  varied  articles  of  diet  should  be 
regulated  by  the  amount  of  proteid  they  contain.  It  is  not  neces- 
sary, however,  that  they  should  exceed  the  other  foods  in  amount  or 
approach  them  in  quantity. 

Russell  H.  Chittenden^  has  clearly  demonstrated  by  his  scientific 
researches  that  the  recommended  dietary  standards  are  excessive 
in  quantity,^  especially  in  regard  to  proteids.  They  do  not  undergo 
complete  oxidation  in  the  body  like  non-nitrogenous  foods,  but 
there  is  left  behind  a  residue  of  non-combustible  matter,  cr3^stalline 
nitrogenous  products,  which  ultimately,  if  occurring  in^  excess  of  the 
requirements  of  the  body,  prove  injurious  to  the  gastro-intestinal 
tract,  liver,  kidneys,  and  nervous  system. 

The  fats  and  carbohydrates  are  easily  eHminated,  becoming 
carbonic  acid  gas  and  water.  Overfeeding  with  a  tendency  to 
obesity  i^  an  evil,  as  the  fat  acts  as  a  mechanic  obstacle  to  the  activity 
of  the  body  and  interferes  with  the  movements  of  the  heart  and 
other  organs;  and,  in  addition,  fatty  degeneration  may  occur. 
Potential  energy,  however,  can  be  fully  as  advantageously  met  by  the 
non-nitrogenous  foods,  carbohydrates,  and  fats. 

Fletcher  has  demonstrated  on  himself  that  deliberation  in  eating, 
necessitated  by  the  habit  of  thorough  insalivation,  results  in  the 
occurrence  of  satiety  on  the  ingestion  of  a  comparatively  small 
amount  of  food,  and  hence  excess  is  avoided. 

It  is  clear  that  a  man  of  170  lbs.  weight  has  more  proteid  tissue 

^  Nutrition  of  Man. 

'^  Physiologic  Economy  in  Nutrition. 


126  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

to  nourish  than  one  of  130  lbs.,  and  consequently  what  will  suffice 
for  the  latter  will  not  for  the  former.  Dietary  standards  are  merely 
approximate  and  depend  on  the  physical  work  to  be  performed,  the 
body  weight,  sex,  age,  climate,  etc.  There  is  doubtless  a  specific 
coefficient  of  nutrition  characteristic  of  the  individual. 

Chittenden  demonstrated  on  professional  men,  soldiers,  and 
athletes  that  they  could  perform  their  duties  with  greater  vigor, 
and  their  strength  as  measured  by  tests,  was  increased  under  dimin- 
ished proteid  diet;  in  fact,  with  about  one-half  the  amount  as 
compared  with  the  standards  suggested, 

CHITTENDEN'S  TABLE 

Fuel  value.i 
60  gm.  of  proteid  are  contained  in —  Calories. 

J  lb.  fresh  lean  beef  (loin) .      308 

9  hens'  eggs 720 

I  lb.  sweetbread.  ...'....  .^ 660 

I  lb.  fresh  liver 432 

f  lb.  lean  smoked  bacon 1820 

f  lb.  halibut  steak 423 

I  lb.  salt  codfish  (boneless) 245 

2i  lbs.  oysters,  solid 506 

J  lb.  American  pale  cheese 1027 

4  lbs.  (2  quarts)  of  whole  milk 1300 

■f  lb.  uncooked  oatmeal 1550 

i^  lbs.  shredded  wheat 2125 

I  lb.  uncooked  macaroni 1665 

I -5  lbs.  white  wheat  bread 1520 

i\  lbs.  crackers • 2381 

if  lbs.  flaked  rice 2807 

f  lb.  dried  beans 963 

if  lbs.  baked  beans 1 1 25 

f  lb.  dried  peas 827 

i^i  lbs.  potato-chips 5728 

f  lb.  almonds 2020 

f  lb.  pine-nuts,  pignolias. 1 138 

I I  lbs.  peanuts 3584 

ID  lbs.  bananas  (edible  portion) 4600 

10  lbs.  grapes 4500 

1 1  lbs.  lettuce 990 

15  lbs.  prunes 5550 

33  lbs.  apples 9570 

The  standards  of  100  gm.  of  proteid  or  more  mean  the  excretion 

of    excessive    nitrogen    through    the    urine.     Chittenden^    found    bv 

experiment  that  the  average  need  of  proteid  food  by  adults  is  fully 

met  by  a  daily  metabolism  equal  to  an  exchange  of  0.12  gm.  of 

nitrogen  per  kilogram  of  body  weight.     This  means  a  cataboHsm  of 

I  gm.  of  proteid  matter  daily  per  kilogram.     The  intake  of  proteid 

food  must  be  somewhat  in  excess  of  proteid  cataboHsm,  since  not  all 

of  the  proteid  is  available,  and  this  is  a  variable  amount  depending 

on  the  proportion  of  animal  and  vegetable  foods  with  their  different 

degrees  of  digestibility  and   availability.     The  required   intake  of 

proteid  Chittenden  places  at  0.85  gm.  per  kilogram  of  body  weight, 

giving  a  maximum  for  safety.     Hence,  for  a  man  weighing  70  kilos. 

^  Fuel  value  of  the  quantity  needed  to  furnish  60  gm.  of  proteid. 
2  Physiologic  Economy  in  Nutrition;  Nutrition  of  Man. 


DIET  127 

(154  lbs.)  there  would  be  required  daily  59.5  gm.  (say,  60  gm.)  of 
proteid  food  to  meet  the  needs  of  the  body.  This  is  about  one-half 
the  Voit  standard,  and  far  below  that  of  many  other  so-called  diets. 
As  the  specialist  is  so  often  consulted  as  to  the  proper  diet  to  maintain 
the  health  of  the  body,  I  quote  Chittenden  at  some  length,  being  a 
firm  believer  in  his  principles. 

The  daily  proteid  requirement  of  60  gm.  can  be  obtained  from 
I  pound  of  uncooked  lean  meat,  of  which  loin  steak  is  the  tvpe. 
Lamb,  veal,  poultry,  or  lean  flesh  of  any  variety,  of  equivalent  weight, 
will  approximately  furnish  the  same  amount  of  proteid. 

Fish,  such  as  halibut  steak,  and  liver  require  |  pound,  and  of 
sweetbreads  |-  pound  are  necessary. 

Of  salt  codfish  h  pound  is  equivalent  to  the  same  weight  of  fresh 
beef,  while  of  lean  smoked  bacon  |  pound  is  necessary. 

Three  hens'  eggs  furnish  one-third  the  arnount  of  proteid  required 
in  twenty-four  hours.  Dried  peas  and  beans,  almonds,  and  pine-nuts 
are  as  rich  in  proteids  as  the  above-mentioned  animal  foods,  and 
essentially  the  same  weight  is  called  for  to  provide  the  daily  require- 
ment of  proteid.  The  same  is  true  of  cheese,  the  composition  of 
J  pound  beiiig  equivalent  to  the  same  amount  of  proteid,  but  of 
much  higher  calorie  value  than  the  equivalent  weight  of  fresh  beef. 

There  are  some  differences  in  digestibility  which  tend  to  lower 
slightly  the  availability  of  the  vegetable  products,  also  of  the  cheese, 
which  necessitates  a  slight  increase  in  the  amount  of  these  foods  to 
equal  the  proteid  value  of  the  equivalent  weight  of  lean  beef. 

Certain  foods  are  poor  in  proteids,  such  as  fruits,  bananas,  grapes, 
prunes,  apples,  etc.,  lettuce,  and,  to  a  less  degree,  potatoes.  These 
are  all  palatable,  but  add  little  to  the  proteids,  even  when  given  in 
large  amount. 

There  is  a  radical  difference  between  the  animal  foods  and  those 
of  vegetable  origin,  in  that  the  fuel  value  necessary  to  furnish  the 
60  gm.  of  proteid  is  small  in  the  former,  as  compared  with  that  of 
the  vegetables;  \  pound  of  lean  beef  with  its  60  gm.  of  proteid  has, 
for  example,  a  fuel  value  of  only  308  calories,  while  §  pound  of  almonds 
has  one  of  2020  calories;  ii  pound  of  cheese  has  one  of  1027  calories; 
h  pound  of  dried  peas,  827  calories.  This  is  due  to  the  proportion 
of  fat  or  oil  present.  With  fat  meat,  such  as  bacon,  the  calorie 
value  rises  in  proportion  to  the  increase  of  fat,  the  prot^d  decreasing 
to  a  greater  or  less  degree. 

A  high  proteid  (animal)  diet  cannot  serve  for  man.  In  a  male, 
for  example,  with  a  weight  of  70  kilos,  and  requiring  2800  calories,' 
it  would  necessitate  the  ingestion  of  4^  pounds  of  beef  to  secure  this 
result,  or  nine  times  more  proteid  than  is  necessary  for  the  system. 

Certain  vegetable  foods  on  the  diet  list,  such  as  flaked  rice, 
crackers,  and  shredded  wheat,  contain  proteids  with  carbolndrates 
and  fat  in  such  proportion  that  the  energy  requirement  would  be  met 
with   essentially  by   the   same   quantity   as  served   to   furnish   the 


128 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


necessary  proteid.  In  potatoes  and  bananas  the  fuel  value  pre- 
dominates over  the  proteid.  The  ideal  diet  is  an  admixture,  such  as 
wheat  bread  with  butter  or  fat  bacon  to  add  to  its  calorie  value, 
shredded  wheat  with  cream,  crackers  with  cheese,  bread  and  milk, 
eggs  with  bacon,  meat  with  potatoes,  etc. 

Two  quarts  of  milk  will  furnish  half  the  requirement  of  an  average 
man,  and  reinforced  b}'  a  i -pound  loaf  of  wheat  bread,  gives  the 
requisite  amount.  A  better  combination  is  I  pound  of  lean  beef, 
§  pound  of  bread,  and  h  pound  of  butter. 

According  to  Chittenden,  for  a  man  of  average  weight  of  70  kilos. 
(154  pounds)  to  provide  the  requisite  quantity  of  food — i.  e.,  60  gm. 
of  proteid  and  2800  calories — the  following  is  a  sample  dietary: 

Proteid.  Calories. 

Breakfast :  Grams. 

I  shredded  wheat  biscuit  (30  gm.) 3.15 

I  teacup  of  cream  (120  gm.) 3.12 

1  German  water  roll  (57  gm.) 5.07 

2  i-inch  cubes  of  butter  (38  gm.) 0.38 

I  cup  of  coffee  (100  gm.) 0.26 


106 

206 
165 

284 


with 

J  teacup  of  cream  (30  gm.) 0.78 

I  lump  of  sugar  (10  gm.) 

12.76 


51 

38 


Lunch  : 


I  teacup  home-made  chicken  soup  (144  gm.) 5 

1  Parker  House  roll  (38  gm.) 3 

2  i-inch  ciibes  of  butter  (38  gm.) o 

I  slice  lean  bacon  (10  gm.) 2 

I  small  baked  potato  (2  ounces — 60  gm.) i 

1  rice  croquette  (90  gm.) 3 

2  ounces  maple  syrup  (60  gm.) 

I  cup  tea  with  i  slice  lemon 

I  lump  sugar  (10  gm.) 


Proteid. 
Grams. 

25 
38 
38 
14 

53 
42 


850 

Calories. 
60 

no 

284 

65 

55 
150 
166 

38 


16.10 


Proteid. 
Dinner :  Grams. 

I  teacup  cream  of  corn  soup  (130  gm.) 3.25 

I  Parker  House  roll  (38  gm.) 3.38 

I  I-inch  cube  of  butter  (19  gm.) 0.19 

I  small  lamb  chop  broiled,  lean  meat  (30  gm.). .  . .      8.51 

I  teacup  of  mashed  potato  (167  gm.) 3.34 

Apple-celery  lettuce  salad  with  mayonnaise  dress- 
ing (50  gm.) 0.62 

I  Boston  cracker  split,  2  in.  in  diameter  (12  gm.) . . .      1.32 

J-inch  cube  American  cheese  (12  gm.) 3.35 

^  teacup  of  bread  pudding  (85  gm.) 5.25 

I  demi-tasse  coffee 

I  lump  sugar  (lo  gm.) • 

29.21 


928 
Calories. 

72 
1 10 
142 

92 
175 


75 

47 

50 

150 

38 


951 


of 


The  total  with  the  dietary  for  the  da)^  amount  to  58.07  gra 
proteid  and  2729  calories. 

These  figures  are  to  be  considered  only  approximately  correct. 

If  a  little  more  proteid  is  required  without  changing  materi?llv 
the  fuel  value,  a  boiled  &gg  can  be  added  to  the  breakfast. 


DIET 


129 


average  egg  of  53  gni.  contains  6.9  gm.  of  proteid  and  increases  the 
fuel  value  by  80  calories.  If  more  vegetable  proteid  is  desired,  a 
soup  of  split  peas  can  be  introduced  without  changing  to  any  great 
degree  the  calories;  thus,  one  teacup  of  split  pea  soup  (1.44  gm.) 
contains  8.64  gm.  of  proteid,  while  the  fuel  value  is  only  94  calories. 

The  addition  of  i  banana  (160  gm).  will  increase  fuel  value 
153  calories,  but  will  only  add  2.28  gni.  of  proteid. 

If  the  fuel  value  is  to  be  increased  without  change  in  the  proteid 
contents  of  the  food,  recourse  can  be  had  to  butter,  fat  of  meat, 
additional  oil  in  salads,  or  to  syrup  and  sugar. 

Wheat  products  abounding  in  starch  still  show  a  large  proportion 
of  proteid;  thus,  shredded  wheat  biscuit  (i  ounce),  which  is  a  type 
of  many  wheat  preparations  from  bread  and  biscuit  to  various 
breakfast  foods,  yield  about  3  gm.  of  proteid  per  ounce  and  100 
calories;  ^  ounce  of  olive  oil  contains  100  calories.  Potato,  chiefly 
a  carbohydrate,  yields  nitrogen  the  equivalent  of  about  I  gm.  of 
proteid  per  ounce.  If  a  large  volume  is  desired  without  much  increase 
in  real  food  value,  there  are  green  foods,  such  as  lettuce,  celery, 
greens  of  various  sorts;  fruits,  such  as  apples,  grapes,  oranges,  etc. 

Meat  augments  largely  the  intake  of  proteid  and  adds  relatively 
a  small  amount  to  the  fuel  value. 

In  edible  nuts  the  content  of  proteid  is  high,  in  some  cases  higher 
than  in  fresh  beef;  while  carbohydrates  and  fat  are  large  in  amount, 
as  in  almonds  and  peanuts. 

In  pine-nuts  and  Brazil  nuts  carbohydrates  are  small  as  compared 
with  peanuts,  almonds,  and  walnuts,  an  important  fact  where  a 
vegetable  rich  in  proteid  is  desired,  but  with  freedom  from  starch 
(see  table). 


Proteid 
present. 

Carbo- 
hydrate 
present. 

Fat 
present. 

Water 
present. 

4.8 
9.2 
6.4 
5-3 
2.5 

Mineral 
present. 

Fuel 
value 
per  lb. 

Almonds  (edible  portion) .... 

Peanuts  (edible  portion) 

Pine-nuts  (edible  portion) . . . 
Brazil  nuts  (edible  portion) . . 
Soft-shell  walnuts 

21.0 

25.8 

33-9 
17.0 
16.6 

17-3 

24.4 

6.9 

7.0 

16. 1 

54-9 
38. 6 

49-4 
66.8 

634 

2.0 
2.0 
3-4 
3-9 
1-4 

3030 
2560 

2845 
3265 
3285 

United  States  Department  Agriculture  Bulletin  No.  28. 

Green  vegetables,  such  as  spinach,  help  the  bowel  action. 

Natural  sugars  are  of  value,  especialh'  such  as  occur  in  oranges, 
grapes,  prunes,  dates,  plums,  and  bananas,  and  to  a  less  degree  in 
apricots,  peaches,  pears,  apples,  figs,  strawberries,  raspberries,  and 
blueberries. 

Apples  when  ripe  and  well  masticated  are  good,  and  a  baked 
apple  is  wholesome. 

There  is  occasionally  an  idiosyncrasy  to  strawberries,  and  some 
suffer  from  fermentation  from  various  fruits. 


I30 


DISEASES   OF  THE   STOMACH  AND  INTESTINES 


A  diet  conforming  to  true  nutritive  requirements  must  tend  toward 
vegetable  food  if  excess  in  proteids  is  to  be  avoided. 

There  is  less  need  for  food  in  hot  weather,  especially  for  fat,  when 
lighter  foods  and  less  calories  are  required. 

We  must  also  remember  that  the  excessive  use  of  salt  strains 
the  kidneys. 

The  following  table  modified  from  that  of  Koenig  and  others, 
gives  the  chemic  composition  of  different  foods  and  the  heat  units 
which  they  produce: 


CHEMIC  COMPOSITION  OF  COMMON  FOOD  SUBSTANCES 

I.  Meats  and  Game. 


Beef  (very  fat)  . .  .  .  , 

Beef  (lean) , 

Veal  (fat) 

Veal  (lean) 

Mutton  (fat) 

Mutton  (lean) 

Pork  (fat) 

Pork  (lean) 

Westphalia  ham .... 

Salted  ham 

Smoked  beef 

Smoked  beef  tongue 
Pulverized  meat. .  . . 

Sweetbread 

Chicken  (fat) 

Chicken  (lean) 

Capon 

Duck  (wild) 

Partridge 

Pigeon 

Hare 

Venison 


Per  cent. 

Nitrogenous 
(proteid). 


17.19 
20.78 
18.88 
19.84 
14.80 
17. 1 1 

14-54 
20.25 

23-97 
22.32 
27.10 
24-31 

64-5 

22.0 

18.49 

19.72 

23-32 

22.65 

25.26 

22.14 

23-34 

19-77 


Per  cent. 
Fat. 


26.38 
1.50 

7-41 
0.82 

36.39 

5-77 
37-34 

6.81 
36.48 

8.68 

15-35 
31.61 

5-24 
0.4 

9-34 
1.42 

3-15 
3-" 
1-43 
1. 00 

I-I3 
1.92 


Per  cent. 

carbohydrate 
(nitrogen  free). 


50 


Calories 
per  100. 


315-81 
99-15: 

146.61 
86.97 

399-31 
123.81 
406.88 
146.36 
453-69 
173-23 
253-76 
393-64 
322.53 

9392 
167.58 

99.10 
135-II 
131-36 
116.85 
100.02 
107.08 
105.44 


II.  Fish. 


Per  cent. 

nitrogenous 

(proteid). 


Per  cent, 
fat. 


Per  cent. 

carbohydrate 

(nitrogen  free). 


Calories 
per  100. 


Eel 

Pike 

Carp 

Shellfish 

Halibut 

Salmon 

Sardellen 

Oysters 

Fresh  herring 
Salt  herring. . 
Caviar 


12.83 

18.34 
20.61 
17.09 
11.94 
15.01 
22.30 

4-95 
10.11 
18.90 
31-36 


28.37 
0.51 
1.09 

9-34 
0.25 
6.42 
2.21 

0.37 

7.11 

16.89 

15.61 


0.53 
0.63 


0.45 
2.85 
0.45 
2.62 

1.57 
2.23 


312.93 

83.57 
94.64 

156.93 
53-66 

132.93 
"3-83 
34.39 
106.15 
247.61 
279.76 


DIET 


131 


III.  Dairy    Products 


Per  cent, 
nitrogenous 
(proteid). 


Cows'  milk 

Cream 

Buttermilk ....... 

Whey 

Kumyss  (cows'      \ 
milk) / 

Butter.-.  .,; 

Cheese  (cream) .... 

Cheese 

Eggs  (hens') 

White  of  egg 

Yolk  of  egg 


3.41  to  4.3 

3.61 

3.0    to  4.0 

•85 

3-65 


0.5 
16.28 

34-99 
12.5 
12.67 
16.24 


Per  cent, 
fat. 


3.0    to  3.8 

26.75 

•93  to  1.3 

-23 

f 
I 
2.07 

90 

41.22 

11-37 
12. 1 
0.25 
31-75 


Per  cent. 

carbohydrate 

(nitrogen  free). 


3.7     to  4.81 

3-52 

3.0     to  4.0 

3-03 

Lactic  acid,  .7 
Alcohol,  1.9 
Carbonic  acid, 
8. 

0-5 
1.90 

5-40 
0-5 

0.12 


Calories 
per  100. 


56.41  to  71.93 
276.01 
33.08  to  43.63 
18 

1 

32.99 

823.1 

449-54 
269.06 

165 

54-22 

355-99 


IV.   Cereals  and  Vegetables 


Per  cent, 
nitrogenous 
(proteid). 


Wheat  bread. . . . 

Rye  bread 

Sago 

Wheat  flour 

Rye  flour 

Cakes 

Roll 

Zwieback 

Cauliflower ..... 

Potatoes 

Asparagus'. 

Carrots 

Rice 

Beans 

Peas 

Spinach 

Oatmeal 

Barley  meal 

Brussels  sprouts. 
Cabbage  (white) . 
Pickles 


6.0 
6. II 
0-5 
8.5 
10.0 

II.O 

6.82 

9.5  to  13.0 


2.0  to 

1-5 
2.0 
1.04 
5-5 

■19-5 

19-5 
2.49 

12.05 
8.31 
4-83 
1.89 
1.02 


5-0 


Per  cent. 

fat. 


0.75 
0-43 
traces 

1-25 

2.0 

4.60 

0.77 

i.o  to  3.0 

0.4 

0.3 
0.21 

1-5 
2.0 
2.0 
-58 
5-26 
o.Si 
0.41 
0.20 
0.09 


Per  cent. 

carbohydrate 

(nitrogen  free). 


Calories 
per  100. 


52.0 

46.0 

86.5 

73-0 

69.0 

73-30 

43-72 

75-0 

4.0 
20.0 

2-5 

6.74 

76.0 

52-0 
54-0 

4-44 
66.77 
75-19 

6.22 

4-87 
0.95 


245 
217.56 
356.70 
345-78 
342.50 
387.09 
213.87 
3.56 
(average) 

35 
88 
20 

33-85 
348.10 

311-75 

319-95 

33-67 

338.80 

323 
49-05 
29.52 
8.81 


132  DISEASES   OF  THE   STOMACH  AND   INTESTINES 

V.  Soups  and  Beverages 


Per  cent. 

nitrogenous 

proteid. 


Per  cent, 
fat. 


Per  cent. 

I  non-nitrogenous 
carbohydrate. 


Calories 
per  loo. 


Meat  broth 

Meat  juice  (expressed) .  .  .  . 

Beef-tea 

( 

Leube's  meat  solution  . .  -{ 

I 

I 

Malt  extract 

Milk  soup  with  wheat 

flour 

Barley  soup 

Rice  pap  with  milk 

Coffee 

Tea 

Beer 

Porter 


0.4 
6.0 


to    7.0 


0.5 

9  to  1 1  albu- 
min and  1.7 
to  6.5  pep- 
ton. 

8.0     to  lO.O 

5-0 
1-5 
8.8 
3.12 
12.38 

0.5 
0.7 


0.6 

0.5 


0.5 


3-25 
i.o 

3-5 
5-i8 

5-25 
6.0 


0.5 


550 

15.0 

II. o 

28.6 


0.3 
0.3 


7.10 
31.20 
(average) 
6.6 

'      86.5 
L (average) 


258-30 

112. 
6o.g6 

182.61 
59-92 
50.75 
510 
60. 


VI.  Fruits,  Nuts,  and  Sugar 


Apples 

Pears. ...... 

Plums 

Peaches 

Apricots.  .  .  . 

Grapes 

Strawberries 
Chestnuts. .  . 
Cane-sugar.  . 
Beet-sugar. . 
Honey 


Per  cent, 
free  acid. 


0.82 
0.20 
1.50 
0.92 
1. 16 
0.79 
0-93 


Per  cent. 

nitrogenous 

proteid. 


Per  cent, 
fat. 


Chiefly  sugar. 


Per  cent. 

non-nitrogenous 

carbohydrate. 


7.22 
8.24 
4.68 
7.17 
4.69 
14-36 
6.78 

38.34 
93-33 
99-75 
73.22 


Calories 
per  100. 


29.6 

33-78 

19.18 

29-39 
19.22 

58.87 
31.88 
192. II 
382.65 
408.97 
305.22 


For  the  determination  of  the  calorie  value  of  each  kind  of  food, 
the  number  of  grams  of  albumin  must  be  multiplied  by  4.1,  the 
grams  of  carbohydrate  by  4.1,  and  the  grams  of  fat  by  9.3,  and  the 
multiples  added  will  give  the  total  calories  as  already  described. 

The  following  diet  Hsts  of  von  Noorden^  demonstrate  the  method 
of  calculating  calorie  values,  and  will  be  found  useful  to  fulfil  their 
indications : 

»Berl.  Klinik,  1838,  J.  55. 


DIET  133 

I.   A  Chiefly  Milk  Diet  with  Addition  of  Carbohydrates  in  Liquid  Form 


Albumin 
(per  cent.)- 

Fat 
(per  cent.)- 

Carbohydrate 
(per  cent.). 

Calories 
per  100. 

Milk,  1 700  cc 

70.2 
10 

7.0 

66.3 

5-5 
71.8 

69.7 
30 

40 

1295 
164 

244 

Soup  of  tapioca  flour,  30 
gm.and  logm.albumose' 

Soup  of  40  gm.  wheat  flour, 
with  some  of  the  milk, 
10  gm.  sugar,  and  one 
ess 

Total 87.2 

139-7 

1703 

II.   A  Chiefly  Milk  Diet  with  the  Addition  of  Carbohydrates  and  Fat  in  Mushes 

and  Soups 


Albumin 
(per  cent.). 

Fat 
(per  cent.). 

Carbohydrates 
(per  cent.). 

Calories 
per  100. 

Good  milk,  1500  cc 

Soup  of  15  gm.  sago,  10  gm. 

butter,    I    egg,     10    gm. 

albumose 

62 
17 

7 

58.5 

13-5 

5-5 

63 
1.5 
90 

1056 
257 

Pap  of  80  gm.  corn  flour, 
I  egg,  10  gm.  sugar  (two 
meals) 

198 

Total 

86 

77-5 

168 

1711 

III.   Milk  Diet  with   Addition  of  Solid  Food,   Pastry,   and  Broths,   Icaviug   little 

Residue 


Albumin                     Fat 
(per  cent.).            (per  cent.). 

Carbohydrates 
(per  cent.). 

Calories 
I)er  100. 

Milk    1250  cc      

51               ,              J-O 

5- 

30 
50 

30 

878 

Meat  broth  with  i  egg,  10 
gm.  of  butter,  50  gm.  of 
fine  toasted  w  heat  bread 

10 

5 

7 

14 
12 

294 

Cakes     70      gm.,     butter 
T  ■;  ffm             

337 

Soup  of    30    gm.    tapioca 
flour,     I     egg,     10    gm. 

282 

Total          

73 

89 

162 

1791 

])reparat 


1  Ten  gm.  albumose  is  contained  in  90  cc.  (3  ounces)   of    Denayer's   peptone 
)aration,  in  22  gm.  (  ovss)  of  Kemmerich's,  or  in  30  gm.  (i  ounce)  of  Koch's. 


134  DISEASES    OF   THE    STOMACH   AND  INTESTINES 

IV.  Milk  with  Tender  Meat,  Solid  Food  (Pastry),  Butter,  and  Soups 


Albumin 
(per  cent.)- 

Fat 
(per  cent.). 

Carbohydrates 
(per  cent.). 

Calories 
per  100. 

Spring  chicken,  loo  gm. .  . 
Mashed  potatoes,  loogm. . 
Two  eggs 

19.6 

2.0 

14.1 

7 
193 
51 

2.8 

4.0 

II.O 

0.5 
23.0 

2.1 

49 

20 

55 

52 

106.4 
127.4 
160  I 

Toasted  wheat  bread  loo 

gm 

Butter,  30  gm    .        

258.8 
213.9 
106.4 

878 

Trout,  100  gm 

MUk,  1250  CO.  and  soups  in 
addition 

Total 

113.0 

92.4 

127 

1851 

V.  Abundant  Non-irritating  Diet 


Albumin 
(per  cent.). 

Fat 
(per  cent.). 

Carbohydrates 
(per  cent.). 

Calories 
per  100. 

Tender  meat,  250  gm.^.  . . . 
Cacao,  20  gm 

49 

4 

21 

8 
7 
4 

51 

7.0 

6.0 

16.0 

I.O 

0-5 

2-3 

44.0 

49 

8 

75 
55 
36 

40 

40 
20 
52 

266 

105 

235 

349-4 

258-75 

187 

407 

164 

164 

82 

Three  eggs^ 

100  gm.  Zwieback 

100  gm.  wheatbread 

50  gm.  cakes 

50  gm.  butter^.. 

40  gm.  tapioca  flour*.  . . . 
40  gm.  corn   flour  (mai- 

zena) 

20  arm.  susrar' 

1250  cc.  milk" 

878 

Total   

144 

125.8 

326 

3096.15 

Digestibility  of  Food. — We  may  say  that  an  article  of  diet  is 
easily  digestible  if  it  makes  small  demand  on  the  secretory  and  motor 
functions  of  the  stomach,  if  it  is  readily  absorbed,  and  causes  no 
subjective  disturbance.  The  scale  of  digestibility  of  foods  has  been 
arranged  according  to  the  length  of  time  that  they  remain  in  the 
stomach,  the  motor  and  secretory  functions  in  the  healthy  stomach 
acting  together,  and  hence  the  length  of  time  the  material  remains 
in  the  organ  indicates  its  digestibility;  good  motor  power  for  a  definite 
food  shows  good  digestion.  In  pathologic  conditions  the  rule  is 
not  as  absolute,   for  either  secretory  or  motor  functions  may  be 

1  Meat  of  various  kinds,  finely  chopped,  raw,  or  broiled  in  butter,  or  roasted, 
cold  or  hot,  given  in  two  meals. 

2  Egg  in  cocoa,  one  in  soup  and  one  raw  or  soft  boiled. 
^  Butter  for  starchy  foods,  soup,  etc. 

*  Tapioca  flour  to  thicken  soup. 

^  Sugar  for  cocoa  and  cornmeal  pudding. 

®  Milk  for  cocoa,  pudding,  and  to  drink. 


DIET  135 

perverted  alone  or  together,  and  sometimes  in  opposite  directions. 
Gastric  digestion  may  also  be  vicariously  assumed  by  the  intestines. 

Leube's  experiments  were  conducted  with  digestion  in  diseased 
stomachs,  and  from  these  he  constructed  his  diet  scale  of  foods 
according  to  their  digestibility.  It  especially  forms  the  basis  of  the 
diet  of  ulcer  (Leube's  method)  and  is  valid  in  many  other  conditions. 

Leube's  Diet  Scale. — Diet  i. — ^With  much  reduced  digestion, 
the  following  are  most  easily  digested :  bouillon,  meat  solutions,  such 
as  Leube-Rosenthal's ;  milk;  raw,  soft-boiled,  or  poached  eggs; 
zwieback;  water,  acidulous  waters  (Apollinaris,  Seltzer). 

Diet  2. — Less  digestible  are  boiled  calves'  brain,  boiled  thymus, 
boiled  chicken  and  pigeon,  boiled  calves'  feet  (with  some) ;  gruels, 
milk,  mushes  made  with  tapioca  and  beaten  white  of  ^^g. 

Diet  J. — If  Diet  2  is  digested,  then  these  can  be  given:  Raw 
beef  (chopped  fine),  or  scraped  meat  with  a  dull  spoon,  and  roast  meat 
scrapings  in  fresh  butter ;  raw  ham  (chopped  fine) ;  a  little  mashed 
potato;  stale  white  bread  and  a  small  amount  of  coffee  or  tea  with 
milk. 

Diet  4.. — Roast  chicken;  roast  pigeon;  venison;  partridge;  roast 
beef,  medium  to  raw  (particularly  cold) ;  veal  (leg) ;  pickerel ;  boiled 
shad;  macaroni;  bouillon  with  rice.  Trout  are  hard  to  digest. 
Small  quantities  of  wine  one  or  two  hours  before  eating.  Gravies 
are  contra-indicated.  Young  and  finely  chopped  spinach  is  best. 
Asparagus  may  be  tried,  but  Leube  considers  it  risky.  After  the 
fourth  diet  the  food  is  gradually  increased,  but  very  gradually. 
Vegetables,  salads,  preserves,  and  fruits  should  be  refrained  from 
for  a  long  time.  A  baked  apple  is  one  of  the  first  of  these  that  can 
be  taken. 

Penzoldt  has  formulated  a  scale  of  digestibility  for  the  normal 
stomach. 

Various  Food  Stuffs. — It  is  important  to  remember  that  we  can 
replace  the  albumin  in  food  by  carbohydrates,  and  at  times  by  the 
fats,  though  the  latter  are  not  always  well  tolerated.  In  many  cases 
the  food  should  be  concentrated,  nourishing,  and  finely  divided,  so 
as  not  to  irritate  the  organ. 

Milk  is  excellent  in  some  cases,  but  in  ulcer,  too  large  quantities, 
at  least  3  liters  (1770  calories),  would  have  to  be  given,  which  tend 
to  overdistend  the  organ. 

Moreover,  raw  milk  remains  in  the  stomach  longer  than  some 
other  forms  of  nutriment,  and  when  given  alone  may  coagulate,  and 
with  some  disagrees.  In  some  experiments  at  the  Manhattan  State 
Hospital,^  in  cases  of  dilatation  of  the  stomach,  it  was  conclu- 
sively shown  that  this  organ  emptied  itself  with  greater  rapidity  in 
proportion  to  dilution  of  the  milk  with  water.  It  is,  therefore, 
preferable  to  give  smaller  quantities  of  milk  and  not  to  administer 
it  alone,  but  diluted  with  barley-water,  for  example,  or  some  other 
^  Medical  Record,  June  20,  1908. 


136  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

amylaceous  material,  such  as  rice-water  or  decoctions  of  tapioca, 
maizena,  etc.  One  can  add  material,  such  as  raw  eggs,  to  increase 
the  calorie  value,  a  large  amount  of  nutriment  in  small  bulk,  as 
described  under  the  treatment  of  gastric  ulcer.  Gartner's  fat  milk, 
from  which  some  of  the  casein  has  been  removed,  is  of  service. 
Buttermilk  has  small  nutritive  value.  Kefir,  koumyss,  bacillac,  and 
matzoon  are  often  useful. 

Meat  broth  and  bouillon  have  little  nutritive  value,  while  beef -tea 
and  expressed  beef-juice  are  of  some  service.  The  latter  is  best 
made  from  the  rump  of  beef,  cut  in  dice,  cooked  for  five  to  ten 
minutes,  and  then  the  beef-juice  expressed  and  pepper  and  salt 
added.  Valentine's  beef -juice  and  Armour's  extract  of  beef  can 
be  recommended  and  are  cheap. 

Gelatinous  articles  of  food,  such  as  gelatin  in  solution,  jellies, 
calves'  feet,  etc.,  are  easily  digested,  as  are  soups  containing  chicken 
or  calves'  brain  finely  macerated  and  forced  through  a  sieve. 

Shellfish,  pike,  halibut,  and  carp  contain  the  least  fat  and  are 
digestible. 

Carbohydrates  should  be  well  masticated  and  carefully  insalivated. 
If  they  contain  much  cellulose  they  are  not  as  readily  digested  and 
should  be  ground  thoroughly.  If  there  is  stagnation  and  so  danger 
of  fermentation,  care  in  their  use  should  be  exercised. 

Ordinary  bread  (rye  or  domestic)  is  not  as  good.  Zwieback, 
toast,  maizena,  tapioca,  oatmeal,  and  LofHund's  kindermehl  are  best. 

Aleuronat  flour  (Ebstein)  contains  80  per  cent,  albumin.  Legu- 
minose  (Hartenstein's),  Liebig's  maltoleguminose,  and  Knorr's 
preparations  are  excellent.  American  veal  has  been  found  by 
experience  to  be  not  very  digestible. 

Fat  in  the  form  of  butter  (50  to  100  gm.)  usually  agrees. 

Coffee  and  tea  may  be  given  in  moderate  amounts  in  many  cases, 
but  considerably  diluted. 

Alcohol. — Wines  are  recommended  by  many  as  a  mild  stimulant 
to  the  stomach  in  certain  cases,  but  from  personal  experience  I  advise 
against  their  use.     There  are  other  remedies  which  give  better  results. 

General  Rules. — The  teeth  should  be  kept  in  good  condition; 
thorough  mastication  and  insalivation  are  important,  and  a  brief 
period  of  rest  after  meals  should  be  advised  both  in  health  and 
disease.     Regularity  of  meals  should  be  enjoined. 

Method  of  Feeding  to  Spare  the  Stomach. — In  some  cases  it  is 
necessary  to  administer  nutriment  in  soluble  or  easily  digested  form. 
Appended  is  a  short  list : 

Hemmerich's  pepton,  somatose,  sanatogen,  tropon,  Koch's 
pepton.  Brand's  meat  preparations,  Valentine's  meat  juice,  Liebig's 
soup,  and  Gartner's  fat  milk. 

Leube- Rosenthal  Meat  Solution. — Chop  i  kilo,  of  beef  into  fine 
pieces,  mixing  it  with  water  (i  liter),  and  add  20  gm.  of  pure  hydro- 
chloric acid  and  boil  mixture  ten  to  fifteen  hours  in  a  Papin  pot. 


DIET  137 

The  mass  obtained  is  crushed,  boiled  fifteen  hours  longer,  neutrahzed 
with  pure  sodium  carbonate,  and  evaporated  to  a  mushy  consistency. 
It  is  digestible,  but  contains  relatively  small  quantities  of  peptone. 

Debove's  Meat  Powder. — Roast  finely  chopped  lean  beef  on  tin 
plates  until  it  is  entirely  desiccated.     Powder  in  a  mortar. 

Haggard. — Cut  lean  meat  into  narrow  strips,  place  for  a  few 
minutes  in  hot  fat  or  lard  until  surface  is  browned,  then  place  on  a 
sieve  for  a  short  time.  Fat  is  allowed  to  drip  off,  and  meat  is  dried 
twenty-four  hours  in  a  baking  oven  at  a  moderate  temperature. 
It  can  be  ground  to  powder  in  a  coffee-mill. 

Rectal  Alimentation. — General  R^lles. — ^The  bowels  should  be 
emptied  by  enema ;  injection  of  the  nutritive  enema  should  be  given 
with  the  patient  on  the  left  side  with  a  colon-tube  several  hours  later; 
temperature  should  be  about  100°  F.  (warm).  A  folded  towel 
should  be  pressed  against  the  anus  and  the  buttocks  pressed  together 
for  at  least  fifteen  minutes  after  the  injection. 

Milk  shoidd  always  he  peptonized,  and  alcohol,  if  injected,  should 
not  be  stronger  than  i :  6  in  the  fluid  enema.  The  addition  of  a 
small  amount  of  salt  aids  absorption.  Dextrose  is  readily  absorbed. 
Occasionally  it  may  be  necessary  to  add  a  few  drops  of  tincture  of 
opium  if  there  is  much  irritation.  Raw  eggs  are  readily  absorbed. 
Sanatogen,  pepton,  and  somatose  are  excellent  additions.  No  more 
than  8  oz.  (250  cc.)  should  be  given  at  an  injection.  It  can  be 
administered  four  or  five  times  a  day.  If  the  bowel  is  irritable, 
smaller  quantities  should  be  employed.  The  patient  should  remain 
quiet  for  one-half  hour  after  the  injection. 

Ewald  suggests  3  to  5  raw  eggs,  mixed  with  150  cc.  of  water  and 
30  gm.  of  grape-sugar,  and  a  small  amount  of  common  salt. 

Boas  uses  250  gm.  milk;  yolks  of  2  eggs;  salt,  tablespoon  of  red 
wine;  tablespoon  of  Kraftmehl. 

I  have  found  the  following  useful:  milk  (peptonized),  125  cc. ; 
sanatogen,  oiij  (12.0);  2  raw  eggs  beaten  up;  water  q.  s.,  250  cc. 
(oviij),  and  a  little  salt.  Modifications  will  readily  suggest  them- 
selves. 

Leube's  Meat  Pancreas  is  Often  Valuable. — To  150  to  300  gm.  of 
scraped  and  finely  chopped  beef  add  50  to  100  gm.  of  pancreas  from 
cow  or  hog,  free  from  fat,  and  finely  chopped. 

The  two  substances  are  placed  in  a  dish  and  150  cc.  of  lukewarm 
water  are  added,  and  the  mixture  stirred  till  it  forms  a  thick  mushy 
mass. 

If  fat  is  also  to  be  digested,  add  25  to  50  gm.  of  fat.  Inject 
with  a  pressure  syringe. 

Enemata  of  normal  saline  solution — .3j  (4.0)  salt  to  Oj  (500  cc.) 
of  water — are  of  value  for  thirst,  or  administered  at  a  temperature 
of  110°  to  120°  F.  as  a  stimulant.  Proctoclysis  is  useful.  If  this 
quantity  is  not  retained,  a  smaller  amount  should  be  employed. 
Subcutaneous   injection   of  fats  I   would   not  recommend.      vSierile 


138  DISEASES    OF   THE   STOMACH   AND   INTESTINES 

almond  oil,   5ss   (2  cc),  might  be  given  three  times  daily  subcu- 
taneously  in  extreme  emaciation  for  a  brief  period. 

Inunctions  with  preparations  of  oil  or  lanolin  may  at  times  be 
of  service. 

DIET  IN  DISEASE 

General  principles  will  be  enmnerated. 

In  acute  diseases  of  the  stomach,  as  in  acute  gastritis,  the  indication 
is  to  spare  the  organ  as  much  as  possible.  In  some  cases  no  food  is 
administered  b}^  mouth  for  several  days  and  rectal  feeding  is 
employed.  If  food  is  administered,  it  should  be  given  in  small 
quantities  at  first  and  in  liquid  form,  weak  broths,  bouillon,  barley- 
water,  a  small  quantity  of  water.  They  should  be  neither  exces- 
sively hot  nor  cold.  Peptonized  milk,  milk  and  hme-water,  white 
of  raw  egg  beaten  up;  later,  toasted  bread,  soft-boiled  eggs, .etc.,  and 
a  gradual  return  to  full  diet. 

Ulcer  of  the  Stomach. — In  this  condition  both  mechanic  and 
chemic  irritation  of  the  stomach  should  be  avoided.  Albumin  solu- 
tions and  finely  divided  proteid  material  are  indicated,  such  as  milk, 
beef-juice,  somatose,  tropon,  or  especially,  sanatogen  in  solution. 

Einhorn  allows  barley-,  oatmeal-,  or  rice-water  in  early  treatment. 
Raw  eggs  beaten  up  aid  in  binding  the  free  acid.  Dextrose  and 
butter  aid  nutrition  and  lessen  acidity.  Starch  in  any  great  quantity 
is  not  well  borne  on  account  of  the  acidity. 

Leube  avoids  all  stomach  feeding  for  several  days  after  the 
hemorrhage,  employing  nutritive  enema;  while  Lenhartz  feeds 
immediately,  binds  the  free  acid,  and  endeavors  to  rapidly  improve 
nutrition.     Gelatin  solutions  are  of  value  in  these  cases. 

Chronic  Diseases  of  the  Stomach. — In  the  chronic  diseases  it 
is  extremely  important  to  see  that  sufficient  quantity  is  taken  and 
to  improve  the  nutrition  of  the  patient,  as  frequently  subnutrition 
is  present. 

Carcinoma. — In  malignant  disease  of  the  stomach  or  its  orifices 
little  can  be  accomplished  by  diet  alone.  The  patient  should  receive 
frequent  meals  in  small  quantities,  liquid  or  pultaceous  in  form. 
This  is  advisable,  even  if  the  cancer  is  so  situated  as  not  to  interfere 
much  with  the  m.otor  function.  I  have  seen  cases  improve  tem- 
porarily in  nutrition.     Radical  or  palHative  operation  is  indicated. 

Benign  Stricture. — Stricture  of  the  cardia  can  at  times  be  dilated 
wdth  bougies;  but  with  pyloric  stricture  perfect  recovery  often 
follows  operation.  With  benign  pyloric  stenosis,  hyperacidity,  at 
times  with  hypersecretion,  and  ectasia  are  present.  The  indications 
in  these  cases  are  to  administer  hquid  or  mushy  foods,  chiefly  of 
albuminous  type.  There  is  relative  motor  insufficiency  and  increased 
secretion.     Starchy  food  in  quantity  is  not,  therefore,  well  borne. 

The  gastric  secretion,  motility,  and  sensibility  of  the  stomach 
must  be  studied  in  every  case. 


DIET  139 

When  there  are  disturbances  of  the  motor  function,  food  should  be 
given  so  prepared  that  it  will  be  most  easily  evacuated  from  the  stomach, 
as  in  liquid  or  pidtaceous  form. 

Among  the  disturbances  of  gastric  secretion  we  have  hyper- 
acidity and  hypersecretion,  an  increase  in  the  secretory  function; 
and  subacidity  and  anacidit}',  an  impairment  of  secretion.  IMotor 
disturbances  may  complicate  any  of  these  conditions,  and  sensory 
disturbances  are  most  frequent  in  the  first  class. 

In  the  hyperacid  forms,  a  diet  should  be  selected  which  stimulates 
hydrochloric  acid  secretion  as  little  as  possible  and  at  the  same  time 
combines  with  it.  Abundant  albuminous  diet  should  be  adminis- 
tered, w'ith  hyperacidity,  in  coarse  form  if  the  motor  function  is 
intact,  otherwise  in  liquid  or  mushy  form.  With  hypersecretion, 
smaller  and  more  frequent  meals  are  indicated,  and  fluids  should  be 
limited.  Carbohydrates  in  any  quantity  are  not  well  borne,  though 
their  digestion  is  better  in  hyperacidity  than  in  hypersecretion.  Solu- 
tions of  dextrose  are  readily  absorbed  and  lessen  the  secretion  of 
hydrochloric  acid.     The  diet  of  ulcer  has  been  previously  referred  to. 

Fats  are  quite  well  borne,  and  in  the  form  of  olive  oil  lessen  the 
hydrochloric  acid. 

In  cases  of  subacidity,  as  in  chronic  gastritis,  meat  must  be 
diminished  and  carbohydrate  material  increased.  Nutrition  must 
be  improved.  Koumyss,  matzoon,  milk,  and  raw  eggs  must  be 
taken  wdth  crackers  and  butter  between  meals. 

As  an  example  of  anacidity  we  have  achyUa  gastrica.  This 
may  be  a  temporary  functional  disturbance  or  a  permanent  condition 
W'ith  organic  changes.  Chemic  action  has  ceased  and  vegetable 
food  (in  which  starch  granules  possess  an  albuminous  coat)  as  well 
as  animal  food  pass  from  the  stomach  unchanged  and  irritate  the 
intestines.  A  rich  carbohydrate  diet  is  indicated,  but  it  must  be 
well  pulverized. 

With  ectasia  and  gastroptosis  small  and  frequent  meals  are 
indicated,  the  character  depending  on  the  gastric  secretion.  With 
severer  forms  of  motor  insufficiency  liquids  and  mushes  are  required. 

In  nervous  dyspepsia  one  must  gradually  increase  the  quantity 
of  food.  '  The  administration  of  frequent  small  meals,  koumyss, 
matzoon,  etc.,  betw^een  the  chief  meals  is  of  value.  The  rest  cure 
is  often  ser^dceable. 

One  must  individualize  in  every  patient,  and  with  the  aid  of  the 
general  principles  described  it  will  be  possible  to  formulate  a  diet 
to  suit  the  case. 


CHAPTER  Vni 

LOCAL  TREATMENT  OF  THE  STOMACH 

LAVAGE 

Since  the  year  1867,  when  Kussmaul  employed  lavage  in  a 
scientific  manner  with  his  stomach-pump  in  the  treatment  of  diseases 
of  the  stomach,  there  has  been  a  gradual  improvement  in  the  type 
of  instrument.  The  hard  tube  and  the  use  of  the  stylet  for  intro- 
duction have  passed  into  disuse,  and  the  modern  method  is  based 
upon  the  principle  of  siphonage  with  the  soft-rubber  tube. 

Funnel  Method. — The  one  that  is  in  most  common  use  for 
washing  the  stomach  is  by  means  of  the  funnel.  The  latter  may  be 
of  hard  rubber,  glass,  or  a  flexible  rubber  funnel,  attached  to  a  piece 


73. — Funnel  and  tube  for  lavage. 


of  soft-rubber  tubing  about  a  yard  long,  the  latter  being  joined  to  the 
upper  end  of  the  stomach-tube  by  a  small  connecting  glass  or  hard- 
rubber  tube  (Fig.  73). 

The  glass  funnel  is  more  readily  broken  and  the  soft-rubber 
funnel  not  as  easily  managed  by  a  novice,  so  that  for  general  use  the 
hard-rubber  funnel  is  preferable.  One  of.  medium  size,  holding 
about  250  cc,  is  most  convenient.  The  glass  connecting  tube,  in 
one  case  to  my  knowledge,  came  near  being  the  source  of  considerable 
danger  to  the  patient.  During  the  lavage  he  suddenly  grasped  the 
glass  tube  and  managed  to  splinter  off  a  portion  of  it,  fortunately 
at  the  same  time  partially  pulling  out  the  stomach-tube.  The 
accident  was  immediately  noted  and  the  tube  entirely  withdrawn. 
Fragments  of  glass  were  found  in  the  tube. 

140 


LOCAL  TREATMENT  OE  THE  STOMACH  141 

There  is  always  the  possibiUty  of  a  similar  accident  to  the  glass 
funnel,  and  the  use  of  a  rubber  instrument  and  metal  or  rubber 
attachment  would  seem  to  be  preferable. 

Dangers. — There  is  one  possible  danger,  namely,  the  stomach- 
tube  may  separate  from  the  attachment  to  the  funnel  tube  and  slip 
down  into  the  stomach.  Leube^  reports  such  a  case.  On  the  ninth 
day  after  swallowing  the  tube — after  an  attack  of  coughing — the 
tube  passed  up  into  the  esophagus  and  pharynx  and  was  withdrawn 
therefrom.  The  connection  between  the  stomach-tube  and  funnel- 
tube  had  become  loosened  and  the  water  from  the  latter  forced  the 
tube  into  the  mouth. 

Moreover,  every  stomach-tube  should  be  tested  before  using  to  be 
sure  that  it  is  not  cracked  or  weakened  by  some  defect. 

Friedenwald"  reports  such  an  accident  resulting  from  the  use  of 
a  defective  tube,  with  the  result  that  two  fragments  were  subse- 
quently removed  by  gastrotomy. 

At  the  Manhattan  State  Hospital,  Ward's  Island,  among  our 
nervous  and  insane  patients,  a  long,  continuous,  single-piece  stomach- 
tube  (3 J  to  4 J  feet  in  length),  with  a  rubber  funnel  at  the  end,  is 
employed.  This  obviates  all  possible  danger  of  swallowing  the  tube, 
which  would  be  the  most  likely  accident  with  this  class  of  patients. 

For  ambulance  w^ork  such  a  tube  is  decidedly  to  be  recommended. 

Under  ordinary  conditions,  with  the  two-piece  tube,  the  patient 
or  an  assistant  can  hold  the  stomach-tube  tightly  at  the  point  of 
junction  with  the  connecting  joint,  or  the  operator  can  hold  it  firmly 
at  the  lips  of  the  patient  when  he  elevates  the  funnel. 


£ 


^O 


Fig.  74. — Best  tube  for  lavage. 


Selection  of  the  Stomach-tube. — The  selection  of  the  stomach-tube 
may  seem  to  be  an  unimportant  matter,  but  from  a  varied  experience 
there  is  undoubtedly  a  decided  advantage  in  the  choice  of  an  instru- 
ment. 

The  tube  should  be  of  value  both  for  aspiration  of  the  stomach 
contents  and  for  lavage.  Some  prefer  the  tube  closed  at  the  end 
and  with  two  lateral  openings,  claiming  that  there  is  less  danger 
of  traumatism  from  the  smooth  rounded  end  and  less  chance  of 
aspirating  the  mucous  membrane  into  the  openings  of  the  tube. 

In  actual  practice,  one  has  to  exercise  more  pressure  with  this 
type  of  tube  in  order  to  force  it  to  take  the  cur\'ature  of  the  stomach 
and  He  parallel  with  the  same,  if  thorough  aspiration  or  lavage  is 
to  be  performed.     This  tube  is,  moreover,  not  so  readily  cleansed. 

The  tube  open  at  the  end  and  with  a  large  lateral  opening  is  prefer- 

1  Deutsch.  Arch.  f.  klin.  Med.,  vol.  xxxiii,  p.  6. 

2  American  Medicine,  August  2,  1902. 


142  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

able;  a  tube  with  two  lateral  openings  is  the  best,  though  not  abso- 
lutely essential  (Fig.  74). 

It  is  much  easier  to  thoroughly  aspirate  the  stomach  or  perform 
lavage  with  tubes  of  this  description.  The  pressure  is  so  minim- 
ized by  these  large  openings  that  in  my  own  experience  I  have  never 
seen  damage  result  to  the  mucous  membrane. 

For  practical  purposes  a  tube  of  from  28  to  30  (French)  is  thor- 
oughly efficient.  I  have  seen  physicians  in  their  general  practice 
employ  tubes  of  very  large  caliber,  irrespective  of  the  size  or  age 
of  the  patient.  This  is  about  as  sensible  as  using  a  large  sound  in 
every  case,  irrespective  of  caliber  or  conditions  of  the  urethra. 

The  tube  of  medium  caliber  that  I  have  indicated  will  pass 
comfortably  through  any  average  or  even  small  adult  esophagus, 
unless  stricture  be  present.  The  best  tubes  are  marked  at  about 
18  inches  from  the  distal  end  (it  is  16  inches  from  the  teeth  to  the 
stomach),  and  by  this  means  we  know  when  the  instrument  has 
reached  that  organ.  The  tube  should  be  inserted  a  little  further 
until  checked  by  the  lower  border  of  the  stomach,  and  then  with- 
drawn slightly  until  no  resistance  is  felt  by  the  operator.  With 
ectasia  or  gastroptosis  it  may  be  necessary  to  pass  it  a  considerable 
distance. 

If  the  tube  is  not  marked  it  is  easy  to  estimate  the  correct  dis- 
tance and  make  a  scratch  mark  on  the  tube  with  a  pencil,  or  insert  it 
until  checked  by  the  lower  border  of  stomach,  as  just  described. 

A  pitcher,  pail  or  large  basin,  towels,  and  rubber  sheets  are 
required.  Special  irrigating  stands  can  be  secured,  but  are  un- 
necessary and  expensive  for  the  young  physician. 

The  correct  method  of  lavage  in  office  practice,  without  an  assist- 
ant, is  first  described.     False  teeth  should  he  removed. 

The  patient  should  sit  upright  in  a  straight  back  chair,  with  a 
rubber  sheet  or  towels  about  the  neck  and  protecting  the  front  of 
the  body.  His  confidence  should  be  gained.  He  should  be  told 
that  the  procedure  is  slightly  disagreeable,  but  absolutely  safe.  He 
should  be  admonished  that  he  is  to  breathe  deeply  and  steadily  all 
the  time,  as  this  will  prevent  the  gagging  and  sensation  of  choking; 
and  he  should  be  directed,  while  the  lavage  is  actually  in  process, 
to  follow  out  this  method. 

The  stomach-tube  should  be  lubricated  by  dipping  it  in  warm 
water.  Vaselin,  cold  cream,  or  olive  oil  may  be  used,  but  they  are 
disagreeable  and  unnecessary.  The  irrigating  fluid  should  be 
pleasantly  warm  to  the  hand.  This  is  sufficient  index  to  the  tem- 
perature, though  for  absolute  accuracy  a  thermometer  may  be 
employed;  and  about  100°  to  10 1  °  F.  is  correct. 

Plain  water  or,  preferably,  normal  saline  solution — .5j  (4-0)  salt 
to  I  pint  (500  cc.)  of  water — is  employed  in  the  average  case  for  the 
purpose  of  cleansing  the  stomach.  Special  solutions  will  be  appro- 
priately indicated  in  their  places. 


LOCAL  TREATMENT  OF  THE  STOMACH 


143 


The  patient  should  bend  the  head  sHghtly  forward  and  open  the 
mouth,  but  not  protrude  the  tongue. 

In  rare  cases  a  2  per  cent,  cocain  or  5  per  cent,  eucain  spray  may 
be  required  if  the  pharynx  is  irritable.  Freezing  the  stomach-tube 
is  also  serviceable. 

The  physician  should  never  insert  his  finger  into  the  mouth  to 
depress  the  tongue  or  act  as  a  guide  to  the  tube,  as  it  renders  the 
operation  more  difficult,  and  will  only  cause  gagging  or  vomiting. 


Fig-  75- — Correct  method  of  passing  the  stomach-lube. 

Most  of  our  text-books  advise  that  the  operator  stand  in  front  of 
the  patient  and  pass  the  tube  along  the  base  of  the  tongue. 

The  most  practical  method  is  the  one  shown  in  Fig.  75. 

The  physician  stands  on  the  right  side  and  a  Httle  back  of  the' 
patient  and  passes  the  left  arm  about  the  neck,  the  fmgers  sttp- 
porting  the  tube  at  the  lips,  the  little  finger  resting  on  the  chin. 

This  method  prevents  the  patient  from  throwing  his  head  back 
and  struggling,  and  gives  the  operator  perfect  control. 

The  stomach-tube  should  be  passed   into  the  mouth  with   the 
right  hand,  it  being  held  about  2  inches  from  the  lips  and  being 


144 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


supported  by  the  left  hand  against  the  roof  of  the  mouth.  It  should 
then  be  rapidly  forced  in  with  the  right  hand,  the  index-finger  and 
thumb  of  the  left  hand  continuously  aiding  its  introduction. 

The  tube  follows  the  arch  of  the  mouth,  and  glides  down  the 
posterior  wall  of  the  pharynx  (Fig.  76).  Interference  from  the  tongue 
is  thus  avoided. 

When  its  progress  is  checked,  the  patient  should  be  told  to 
swallow  and  it  will  enter  the  esophagus.  It  should  now  be  rapidly 
fed  into  the  mouth  until  the  marked  ring  has  been  reached,  and 
then  more  slowly  to  the  bottom  of  the  stomach. 

If  the  tube  is  checked  during 
introduction,  it  is  probably  due 
to  a  spasm  of  the  esophagus,  and 
the  act  of  swallowing  or  a  deep 
inspiration  will  free  it.  There  is 
practically  no  danger  of  its  en- 
trance into  the  larynx. 

Sometimes  the  patient  ma}^ 
become  cyanotic  and  a  beginner 
may  fear  that  this  has  happened ; 
but  this  is  due  to  the  fact  that 
the  breath  is  held,  and  deep  and 
regular  breathing  will  immedi- 
ately relieve  the  condition. 

Occasionally  the  tube  may 
slip  out  of  the  esophagus  and 
coil  in  the  mouth,  but  that  is 
easily  detected.  Patients  accus- 
tomed to  lavage  can  often  intro- 
duce the  tube  themselves. 

I  prefer  a  funneP  of  a  capacity 
of  250  cc.  or  about  8  ounces,  and 
allow  2  funnelfuls  to  run  into  the 
stomach  (in  all  about  i  pint)  and 
to  run  out  again  at  once.  It  is  a  bad  practice  to  overdistend  the 
stomach,  just  as  it  is  the  bladder.  At  times  I  emplo}^  i  funnelful. 
Lavage  is  continued  until  the  water  is  perfecth^  clear.  The 
patient  may  move  the  body  about  so  as  to  bring  the  water  in  more 
thorough  contact  with  the  stomach  wall,  or  may  lie  down,  as  sug- 
gested by  Kleiner,  rotating  to  the  right  side  and  then  to  the  left; 
but  this  is  rarely  necessary  except  in  cases  of  marked  dilatation 
with  insufficiency. 

Lavage  by  a  Single  Operator. — During  lavage  the  patient  steadies 
the  stomach-tube,  holding  it  to  the  lips  with  one  hand.  He  should 
be  instructed  not  to  bite  the  tube. 

1  If  the  funnel  is  of  smaller  capacity,  more  funnelfuls  should  be  used,  total 
250  to  500  cc.  (8  ounces  to  i  pint). 


Fig.  76. — Course  of  tube. 


LOCAL  TREATMENT  OF  THE  STOMACH 


145 


The  operator  holds  the  funnel  in  the  left  hand  and  pours  the 
water  into  it  from  a  pitcher  in  the  right  hand,  then  elevates  the 
funnel  to  about  the  level  of  the  patient's  forehead  (Fig.  77). 

As  soon  as  it  is  empty,  he  pours  in  the  second  funnelful.  Then 
before  the  latter  is  empty  he  quickly  lowers  it  to  below  the  level  of 
the  patient's  stomach,  and  allows  the  fluid  to  siphon  out  into  a  pail 
or  bowl  placed  on  the  floor  to  the  right  of  the  patient  (Fig.  78). 

The  rim  of  the  funnel  should  be  held  upward.  It  should  be 
allowed  to  fill  before  emptying  it,  as  in  this  way  it  can  be  estimated 


fig.  -J-. — Lavage  by  single  operator:  Position  one. 

whether  the  amount  of  fluid  that  flows  out  equals  that  which  was 
poured  in.  In  emptying  the  funnel  it  should  only  be  slightly  tipped, 
so  that  the  column  of  water  is  still  visible  in  the  bottom.  This 
prevents  the  entrance  of  air  and  also  the  aspiration  of  the  mucous 
membrane  into  the  openings  of  the  tube. 

When  the  washing  is  completed,  the  funnel  should  be  rapidly 

10 


146 


DISEASES    OF   THE    STOMACH   AiXD    INTESTINES 


raised  and  the  stomach-tube  withdrawn  in  this  position.  The  small 
column  of  water  remaining  in  the  tube  flows  back  into  the  stomach 
and  prevents  the  possibility  of  the  accident  just  noted.  The  tube 
should  not  be  pinched  during  the  withdrawal,  as  mucous  membrane 
might  be  aspirated  in. 

If  the  water  stops  flowing  during  lavage,  one  should  observe  if 
the  patient  has  not  inadvertently  withdrawn  the  tube  slightly;  and 

in    this    event,    it    should    be 
pushed  back. 

On  the  other  hand,  the 
tube  may  be  bent  and  the  flow 
stopped  by  reason  of  its  being 
forced  too  far  into  the  stomach. 
If  so,  withdrawing  it  slightly 
will  correct  the  trouble. 

Pieces  of  food  may  occlude 
the  tube  by  stopping  up  the 
stomach  openings.  By  pour- 
ing more  water  into  the  funnel 
the  instrument  will  usually  be 
cleared  out.  By  forcing  air 
through  the  stomach-tube  or 
by  suction  this  can  be  accom- 
plished if  the  above  method 
fails.  Thus,  a  rubber  bulb 
with  metal  attachments  is  in- 
serted between  the  stomach- 
tube  and  the  funnel-tube,  in 
place  of  the  tube  joining  them. 
Close  the  end  leading  to  the 
funnel  and  compress  the  bulb. 
This  will  force  air  through  the 
stomach -tube;  or  first  com- 
press the  bulb,  then  close  the 
distal  end  connecting  with  the 
funnel  by  making  an  angle  or 
compressing  the  soft  tube  of 
the  lat  er  then  let  the  rubber  bulb  expand  again.  The  last  method 
described  is  that  originated  by  FriedHeb.  The  stiff  rubber  bulb 
made  by  Tiemann,  with  metal  attachments,  is  a  better  instrument 
than  Friedlieb's,  which  has  glass  attachments. 

On  rare  occasions  it  may  be  necessary  to  remove  the  tube,  clean 
it,  and  reintroduce  it. 

In  emergency  in  country  practice  one  can  employ  an  ordinary 
tin  kitchen  funnel  and  a  piece  of  small  red  or  even  white  rubber 
tubing.  A  fountain  syringe  with  the  long  soft-rubber  tubing  has 
been  used  in  poison  cases.     A  stomach-tube  can  be  improvised  out 


Fig.  78. — Lavage  by  single  operator:  Posi 
tion  two. 


LOCAL  TREATMENT  OF  THE  STOMACH 


147 


of  a  long  colon-tube.  The  lateral  opening  can  be  cut  with  a  pair  of 
sharp  scissors,  and  the  rough  edges  of  the  window  burned  over  an 
alcohol  lamp,  wiping  them  quickly  with  a  wet  cloth,  thus  making  a 
smooth  velvet  eye.  If  the  opening  of  the  improvised  tube  is  rough, 
it  can  be  trimmed  down  and  smoothed  b)^  the  above  method. 

It  is  best  to  lubricate  all  such  emergency  tubes  with  ohve  oil  or 
vaselin,  as  they  are  less  smooth  and  more  difficult  of  introduction- 


Fig.  79. — Lavage  by  two  nurses:  Step  one. 

With  an  intelhgent  patient  who  will  co-operate  with  the  physician 
the  method  described  is  excellent.  In  nervous  cases,  when  pos- 
sible, it  is  easier  to  have  an  assistant,  or  for  two  nurses  to  perform 
lavage,  as  in  Figs.  79  and  80. 

The  technic  is  the  same  as  to  passage  of  the  tube,  etc.  One 
nurse  steadies  the  tube  at  the  patient's  mouth  and  carries  on  the 
manipulation  with  the  funnel,  the  other  pouring  the  fluid. 


148 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


10 


L 


Fig.  80. — Lavage  by  two  nurses:  Step  two. 


Fig.  81. — Friedlieb's  apparatus  for  lavage. 


LOCAL  TREATMENT  OF  THE  STOMACH 


149 


If  the  patient  resist,  nurse  No.  i  both  holds  the  tube  and  prevents 
interference  by  the  patient's  hands,  while  nurse  No.  2  manages  the 
funnel  and  pours  the  fluid.  Friedlieb's  apparatus  is  demonstrated 
in  Fig.  81. 

In  Figs.  82  and  83  we  have  two  nurses  performing  lavage  with  a 
funnel,  the  modified  Frtedlieb  bulb  connecting  the  stomach-tube  and 
funnel-tube.     This  is  a  favorite  method  of  mine. 


Fig.  82. — Nurses  performing  lavage  with  modified  Fnedlieb  bulb:  Step  one. 

It  is  best  to  close  the  bulb  on  the  side  joining  the  stomach-tube 
by  pinching  the  latter  with  the  fingers,  then  squeeze  out  the  air  and 
pour  the  fluid  into  the  funnel,  allowing  the  bulb  to  fill  with  water. 
This  prevents  aspirating  air  into  the  stomach.  Lavage  is  then 
performed  in  the  usual  way.  The  advantage  is  that  we  have  the 
bulb  in  position  to  employ  air  pressure  or  suction  if  the  stomach-tube 
becomes  occluded.  Intermittent  squeezing  of  the  bulb  also  aids 
expulsion  of  the  fluid. 


I50 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


The  modified  bulb  made  by  Tiemann  has  metal  connections 
(instead  of  glass)  and  is  stiffer  than  Friedlieb's. 

Irrigation  of  the  Stomach  by  Means  of  a  Glass  Y  or  T- — 
This  method  has  generally  been  known  as  Leube-Rosenthal's,  but 
R.  H.  M.  Dawbarn  has  taught  this  plan  for  many  years.  It  is 
useful  for  office  work. 

A  large  glass  irrigator,  about  2-quarts  capacity,  is  hung  at  a 
level  slightly  above  the  patient's  head.     This  should  be  marked  in 


Fig.  83. — Nurses  performing  lavage  with  modified  Friedlieb  bulb:  Step  two. 

250  to  2000  cc.'s,  or  in  otmces  or  pints.  This  irrigator  is  con- 
nected with  a  long  soft-rubber  tube  by  means  of  a  Y"  or  J-shaped 
glass  or,  preferably,  hard-rubber  or  metal  tube;  one  branch  with  the 
stomach-tube  and  the  other  with  a  carry-off  tube  which  passes  down 
into  a  pail  or  basin. 

The  irrigator  tube  should  be  closed  with  a  clamp.  This  is- kept 
closed  until  after  the  introduction  cf  the  stomach-tube  and  com- 
mencement  of   lavage.     A   second   clamp   on   the   outflow   tube   is 


LOCAL  TREATMENT  OF  THE  STOMACH 


151 


unnecessary,  as  all  manipulation  can  be  thereafter  conducted  by  the 
operator,  by  alternately  opening  and  closing  the  inflow  and  outflow 
tubes  with  the  fingers. 

The  stomach-tube  is  introduced  in  the  way  described.  The 
outflow  is  pinched  as  in  Fig.  84  and  the  clamp  on  the  inflow  tube 
opened.     Only  500  cc.  of  fluid,  or  about  i  pint,  is  allowed  to  fl.ow 


Fig.  84. — Stomach  irrigation  hy  the  T-method;  First  step. 

into  the  stomach.     I  do  not  approve  of  employing  the  larger  quanti- 
ties as  recommended  by  some  authors. 

While  the  fluid  is  still  entering,  the  outflow  tube  is  suddenly 
released  and  part  of  the  current  is  diverted,  thus  starting  the  siphon 
action.  The  inflow  tube  is  then  pinched,  as  in  Fig.  85.  and  the 
stomach  rapidly  empties  itself.  The  outflow  is  then  pinched  and 
the  inflow  released,  and  so  on.  The  patient  may  shake  his  abdo- 
men, so  as  to  wash   all  parts  more  thoroughly. 


152 


DISEASES    OF   THE    STOMACH   AND    INTESTINES 


This  procedure  must  be  continued  until  the  wash-water  returns 
clear. 

There  are  cases  among  the  insane  or  when  the  patient  is  uncon- 
scious when  the  methods  described  cannot  be  used. 

It  may  be  necessary  to  employ  a  mouth-gag,  forcibly  distend  the 
jaws,  and  force  in  the  stomach-tube.  Under  such  conditions  niuner- 
ous  assistants  may  be  required. 


Fig.  85. — T -method:  Second  step. 

The  operation  may  be  performed  with  the  patient  lying  on  the 
back,  being  properly  restrained.  The  tube  should  be  passed  along 
the  roof  of  the  mouth,  and  the  patient  should  lie  on  a  sufficientlv 
high  level,  so  that  the  funnel  can  be  carried  below  the  level  of  the 
body  in  order  to  secure  the  siphon  effect. 

If  no  mouth-gag  can  be  secured,  the  handle  of  a  spoon,  protected 
with  gauze  or  a  handkerchief,  can  be  inserted  between  the  teeth. 
turned,  and  the  jaws  forced  apart,  or  some  such  instrument  improvised. 

The  director  devised  by  Mark  Knapp  (Fig.  86)  would  be  of  value 


LOCAL,  TREATMENT  OE  THE  STOMACH 


153 


in  sucTi  cases.  Being  all  metal,  it  can  be  left  in  situ  during  lavage, 
and  acts  as  a  gag. 

The  simplest  method  in  such  cases  is  to  introduce  the  tube  through 
the  nostril. 

The  technic  of  lavage  by  this  method  is  shown  in  Figs.  87  and  88. 

The  tube  is  passed  along  the  floor  of  the  nostril,  just  as  is  the  guide 
for  posterior  nasal  tamponnade.  It  is  fed  directly  through  the 
nostril  for  about  20  inches,  and  no  difficulty,  as  a  rule,  is  experienced, 
as  it  passes  down  the  posterior  wall  of  the  pharynx  and  so  on  into 
the  esophagus. 


r1 


J^Wmttl^^^^^ 

CL- 

Ja 

ai 

^ 

1 

J" 

^T 

^ 

'       ('i                                                      "^^ 

\_^-|^ 

cZ 



— 

— --^ 

Fig.  86. — Knapp's  director. 

The  nares  should  be  examined,  and  that  nostril  selected  which 
is  of  larger  dimensions.  This  is  important,  as  there  are  frequently 
deflections  of  the  septum. 

At  the  Manhattan  State  Hospital  a  stomach-tube  of  fair  size 
(about  27,  French)  is  employed.  I  frequently  use  this  tube  in  my 
office  lavage  per  orem.  It  is  rarely  necessary  to  employ  the  very 
small  tubes  so  frequently  recommended.  For  thorough  lavage  a 
fair  caliber  is  preferable. 

Gavage  is  a  different  proposition  and  the  small  tubes  are  to  be 
preferred.^ 

Hemmeter  and  others  have  employed  double-current  tubes  for 
lavage,  but  1  can  see  no  advantage. 

Indications  for  Lavage. — i.  In  All  Cases  of  Poisoning. — Some 
authors  advise  against  it  in  cases  of  acids  or  alkalis,  for  fear  of  causing 

1  Gavage  or  forced  feeding  is  employed  chiefly  among  the  insane  who  refuse 
food,  the  tube  being  introduced  as  in  lavage,  the  nasal  route  being  preferable. 


154 


DISEASES    OF   THE    STOMACH    AND   INTESTINES 


perforation;  but  there  is  greater  danger  of  the  latter  by  leaving  the 
poison,  since  thorough  emesis  cannot  be  secured,  especially  if  the 


Fig.  87. — Lavage  through  the  nostril:  First  step. 


Fig.  88. — Lavage  through  the  nostril :  Second  step. 

patient  be  unconscious;  there  is  the  increased  danger  of  subsequent 
'damage  to  the  intestinal  canal  below  and  often  to  the  other  organs, 


LOCAL  TREATMENT  OF  THE  STOMACH  1 55 

such  as  the  Hver  and  kidneys,  or  cardiac  or  respiratory  poisoning 
■might  result. 

2.  In  acute  and  uncontrollable  vomiting  from  any  cause,  as  from 
acute  gastritis,  the  value  of  lavage  was  first  definitely  shown  bv  our 
specialists  in  pediatrics.     Bihous  vomiting  is  included. 

3.  In  chronic  gastritis,  with  excessive  production  of  mucus. 

4.  In  dilatation  of  the  stomach  (atonic  type),  where  there  is  marked 
fermentation  and  motor  insufficiencv. 

5.  In  dilatation  of  the  stomach  (stenotic  type),  with  fermentation, 
motor  insufficiency,  gastritis,  etc. 

6.  In  acute  dilatation  of  the  stomach  from  all  causes. 

7.  In  vomiting  due  to  vicious  circle,  after  gastro-enterostomy. 

8.  At  the  end  of  anesthesia,  to  prevent  post-operative  vomiting, 
or  to  treat  the  same,  if  it  has  occurred. 

9.  In  post-operative  intestinal  paresis  (correctly,  gastro-intestinal 
paresis)  lavage  should  be  employed  together  with  enteroclysis. 

10.  In  acute  tympanitis  of  typhoid  fever  lavage  is  of  great  value  to 
aid  reduction  of  the  same;  especially  when  hemorrhage  is  occurring 
and  enteroclysis  is  contra-indicated. 

11.  In  intestinal  ohstructio7i,  especially  in  intussusception.  Fre- 
quent lavage  has  so  relieved  abdominal  distention  above  the  point  of 
obstruction  that  the  condition  has  been  spontaneously  reduced. 
It  also  checks  the  vomiting  in  this  condition. 

12.  Occasionally  lavage  with  iced  water  has  proved  successful 
in  uncontrollable  hemorrhage  from  gastric  ulcer.  It  should  be  used 
as  a  last  resort  and  with  great  caution. 

13.  It  is  also  of  service  in  estimating  the  degree  of  motor  itisuffi- 
ciency  by  washing  out  the  residue  after  aspiration  following  the 
test  meal. 

14.  In  gastric  tetany. 

15.  In  the  convulsions  of  young  children  which  immediately  follow 
the  ingestion  of  improper  food.  Epileptiform  convulsions  occasion- 
ally occur  in  adults  from  overfeeding  and  lavage  is  indicated. 

16.  In  vomiting  of  peritonitis. 

Centra-indications    to    Lavage. — i.   Aneurysm  of  the  aorta. 

2.  Gastric  hemorrhage,  as  a  general  rule,  except  as  in  No.  12  above. 

3.  Marked  heart  lesions,  when  danger  might  be  incurred,  such 
as  in  angina,  etc. 

4.  Last  months  of  pregnancy. 

5.  Special  conditions  where  it  might  damage  the  patient  or  be. 
dangerous. 

In  cases  of  poisoning  lavage  would  take  precedence  over  all  other 
risks. 

6.  Recent  rectal,  vesical,  or  renal  hemorrhage. 

7.  Recent  hemoptysis. 

8.  Extreme  prostration  from  an>'  cause. 

Stomach  Douche. — This  method  was  first  described  by  Malbranc, 


156  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

and  the  measure  was  first  employed  by  Kussmaul.  It  consists  in 
sprinkling  the  stomach  with  water  under  pressure.  Ewald  and 
Rosenheim^  have  devised  the  most  practical  stomach-tubes  for 
this  purpose. 

The  instrument,  as  in  lug.  89,  has  numerous  small  lateral  openings 
and  a  slightly  larger  hole  at  the  end.  This  last  is  so  that  the  water 
can  run  off  more  rapidly  in  emptying  the  stomach,  and  any  mucus 
or  food  products  can  more  readily  escape.  If  the  hole  is  too  large, 
the  bulk  of  the  fluid  will  pass  through  this  and  no  diffuse  irrigation 
of  the  mucous  membrane  be  accomplished. 

The  tube  is  introduced  in  the  manner  already  described,  and  the 
funnel  method  is  employed.  This  is  held  quite  high  above  the 
patient,  so  that  the  water  is  under  considerable  pressure  and  numer- 
ous small  streams  are  forced  out  of  the  tube. 

Rosenheim  recommends  it  on  an  empty  stomach  before  break- 
fast or,  if  this  is  impractical,  three  or  four  hours  after  the  first  meal. 
It  is  applicable  to  mild  motor  insufficiency.  Rosenheim-  advises 
its  use  in  mild  cases  of  chronic  catarrh  and  in  irritation  of  the  sensory 
and   secretory  apparatus. 


Fig.  89. — Stomach  douche. 

Salt  added  to  the  irrigation  fluid  increases  the  hydrochloric  acid 
production,  nitrate  of  silver  (in  i :  1000  strength)  reduces  the  secre- 
tion of  gastric  juice.  Other  observers  have  agreed  with  these  findings, 
and  Riegel  advocates  the  use  of  the  silver  nitrate.  Fleiner^  recom- 
mends the  douche  for  stimulating  the  appetite.  Thus,  infusions  of 
hops,  quassia,  condurango,  or  cinchona  bark  are  valuable. 

Boracic  acid,  salicylic  acid,  sodium  salicylate,  thymol,  gomenol, 
creolin,  lysol,  etc.,  may  be  employed  in  average  strength  (i:  1000) 
if  antiseptic  treatment  is  indicated. 

If  medicated  douches  are  employed,  the  stomach  should  first  be 
washed  with  plain  water;  then  the  medicated  fluid  applied  for  one 
to  three  minutes  and  then  siphoned  out;  the  stomach  should  be 
rewashed  ^vith  plain  water  if  toxic  materials  have  been  used. 

Gross  has  devised  a  doiihle-currcnt  gastric  douche,  which  is  scarcely 
practical,  and  Einhorn  an  instrument  with  a  ball-valve  and  hard- 
rubber  tip. 

1  Therapeut.  Monatsch.,  August,  1892. 

-  BerUn.  Klinik,  1894,  No.  71. 

3  Samml.  klin.  Vortrage,  New  Series,  No.  103. 


LOCAL  TREATMENT  OF  THE  STOMACH 


157 


The  following  simple  addition  to  the  Ewald -Rosenheim  tube 
-gives  satisfactory  results.  Employ  a  fountain  syringe  instead  of  a 
funnel  and  also  a  compression  bulb  (Fig.  90). 

The  stomach  douche  is  passed  in  the  usual  way  and  the  bulb 
(aspirating)  joins  it  to  the  fountain  syringe,  which  contains  the 
irrigating  fluid  at  a  temperature  of  100°  F.  Clip  X  is  previously 
closed.  The  tube  is  pinched  tightly  at  A  and  the  clip  then  opened. 
By  squeezing  the  bulb  B,  all  air  is  driven  out  through  the  fountain 
syringe  C.  The  bulb  is  then  released  and  fills  with  fluid.  This 
prevents  air  from  entering  the  stomach.  The  finger  releases  the  tube 
at  A  and  the  fluid  begins  to  flow  into  the  stomach;  and  by  inter- 
mittent pressure  of  bulb  (B)  the  spraying  effect  can  be  intensified 


&UL 


Fig.  90. — The  bulb-com- 
pression method  of  spray- 
ing the  stomach. 


Fig.    91. — The    Y-method    of    spraying    the 
stomach. 


at  the  will  of  the  operator.  When  the  douching  is  completed  the 
bulb  is  detached  from  the  fountain  syringe  and  with  pressure  of  the 
same — the  thumb  over  the  end — sHght  aspiration  is  commenced 
and  the  contents  will  then  siphon  out. 

In  Fig.  91  is  illustrated  the  Y-method  of  spraying  the  stomach. 
The  technic  is  the  same  as  the  similar  procedure  in  lavage. 

In  Fig.  92  the  use  of  the  alternate  hot  and  cold  douche,  with 
pressure  bulb,  is  depicted. 

The  addition  of  the  bulb  enables  one  to  employ  the  spray  with- 
out distending  the  stomach  with  air,  and  to  reach  much  further  than 
with  simple  hydrostatic  pressure.  When  stronger  medicaments  are 
employed,  the  rapid  emptying  of  the  stomach  within  one  to  two 
minutes  and  immediate  lavage  eliminate  all  danger,  especially  in 


158 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


view  of  the  fact  that  by  the  compression  method  of  spraying  much 
less  fluid  is  required,  as  compared  with  the  older  procedures. 

The  temperature  of  the  fluid  should  be  about  ioo°  F.  When 
stimulating  effects  are  required  it  could  be  103°  to  105°  F.;  if  cold, 
at  75  °  to  80  °  F.  when  used  with  the  alternate  douche. 

In  atony,  with  or  without  commencing  dilatation,  the  spray 
method,  employing  in  all  not  over  ^  pint  to  li  pints,  is  at  times  of 
service  to  stimulate  the  organ.     With  this  exception,  I  rarely  use  it. 


CUP 


Fig.  92. — The  alternate  douche. 


Gastric  Spray. — This  consists  of  an  ordinary  spray  apparatus 
with  a  double  bulb,  to  which  is  attached  a  soft  Nekton  tube  70  cm. 
long;  within  this  is  a  fine  central  flexible  tube,  which  connects  the 
inner  capillary  tube  with  the  nozzle  (Fig.  93). 

Einhorn\  who  devised  the  tube,  recommends  it  highly,  as  therebv 
one  employs  a  small  amount  of  fluid  to  secure  results;  and  hence, 
there  is  less  danger  w^hen  toxic  or  irritating  substances  are  used. 

^  New  York  Medical  Journal,  Sept.  17,  1892. 


LOCAL  TREATMENT  OF  THE  STOMACH  1 59 

The  spray  should  be  employed  when  the  patient  has  fasted  or 
after  a  previous  lavage.  The  bottle  is  filled  with  the  required 
amount  of  the  antiseptic  solution,  the  tube  dipped  in  warm  water, 
and  introduced  in  the  usual  manner. 

The  patient  should  hold  the  tube  at  the  lips  and  the  operator 
steady  the  bottle  and  compress  the  bulb.  The  spraying  should  be 
begun  when  the  tube  has  entered  to  the  mark  (about  16  inches). 
It  can  be  forced  further  in. 

Einhorn  advocates  it  to  disinfect  the  mucous  membrane  of  the 
stomach;  for  the  application  of  astringents;  and  to  relieve  pain  in 
gastralgia,  as  from  ulcer,  cicatrix,  or  cancer. 

It  is  recommended  in  erosions  of  the  stomach;  in  chronic  gas- 
tritis, with  marked  production  of  mucus;  in  hypersecretion  and 
hyperacidity,  and  in  gastralgia. 


Fig.  93. — Einhorn's  gastric  spray. 

Riegel  holds  that  the  necessary  insufflation  of  air  distends  the 
stomach,  and  on  this  account  it  is  objectionable.  I  have  found  the 
spray  of  value  in  gastralgia  and  in  the  treatment  of  erosions. 

STOMACH  POWDER-BLOWER 

A  dry  method  for  spraymg  the  stomach  w'ith  insoluble  substances 
(powders)  has  been  devised  by  Einhorn.^  His  instrument  consists 
of  a  flexible  rubber  tube  about  28  inches  long  (Fig.  94),  the  distal 
end  of  which  connects  wdth  an  air  suction-bulb. 

The  extremity  of  the  tube  is  attached  to  a  hard-rubber  piece  c, 
which  is  hollow  and  has  lateral  openings.  It  is  provided  with  a 
screw  thread.  To  this  is  attached  a  capsule  with  numerous  side 
holes.  Capsules  of  several  sizes  are  furnished.  A  capsule  is  filled 
with  powder  and  screwed  on  to  the  tip  piece.  A  small  spoon  is 
employed  to  fill  the  capsule. 

It  is  well  to  lubricate  the  latter  with  a  thin  layer  of  vaselin  to 
prevent  entrance  of  moisture.  The  tube  is  then  dropped  into  warm 
1  New  York  Medical  Journal,  Ai)ril  i,  1899. 


i6o 


DISEASES   OF   THE   STOMACH  AND  INTESTINES 


Fig.  94. — I.  The  stomach  powder-blower:  a,  the  tubing  part;  b,  connection 
with  the  bulb;  c,  hard-rubber  end  with  screw  thread  for  capsule;  2,  the  capsule- 
shaped  powder  receptacles  (natural  size);  3,  the  small  spoon  for  putting  the 
powder  into  the  capsule. 


Fig.  95. — New  model  powder-blower. 

water  and  inserted  into  the  stomach  in  the  usual  manner.  The 
bulb  is  quickly  compressed  several  times  and  the  air  drives  out  the 
powder,  opening  up  the  vaselin  layer  over  the  holes. 


LOCAL  TREATMENT  OF  THE  STOMaCH  i6i 

It  has  been  recommended  for  ulcer  of  the  stomach,  employing 
bismuth  subnitrate;  in  gastralgia,  orthoform;  and  in  erosions,  pro- 
targol  or  suprarenal  powder. 

I  would  not  care  to  advocate  the  passage  of  the  instrument  in 
ulcer,  but  in  the  other  conditions  it  is  at  times  of  service.  Recently 
Einhorn  has  modified  this  instrument  (Fig.  95).  There  is  a  double- 
bulb  with  a  stop-cock.  This  last  is  closed.  Bulb  a  is  compressed 
several  times,  thus  overdistending  bulb  b,  which  is  without  valves. 
The  stop-cock  is  opened  and  a  single  blast  of  air  distributes  the 
powder ;  about  15  gr.  ( i  .0)  is  the  capacity  of  the  capsule. 

ELECTRICITY 

From  clinical  experience  it  is  found  that  the  electric  current 
exercises  an  influence  on  the  secretory  and  motor  functions  of  the 
stomach  and  also  on  its  sensibility.  Physiologic  experiments  and 
clinical  experience  do  not  always  agree. 

]\Ieltzer,  experimenting  on  animals,  passed  strong  induced 
currents  through  the  fundus  of  the  organ  and  noted  no  contraction 
of  the  pylorus.  The  influence  of  the  anesthetic  or  of  morphin  or 
similar  drugs  would  influence  the  experiment. 

Pepper  demonstrated  on  a  very  thin  patient  that  percutaneous 
electricity  produced  no  peristaltic  movements  in  the  stomach.  It  is 
believed  that  it  is  through  contraction  of  the  abdominal  muscles  that 
this  procedure  influences  the  musculature  of  the  stomach.  The 
two  methods  for  the  application  of  the  galvanic  and  faradic  current 
are  the  percutaneous  and  the  intraventricular.  The  latter  seems 
preferable  from  a  therapeutic  standpoint,  but  the  former  is  easier  and 
is  more  readily  submitted  to  by  patients. 

Percutaneous  Method. — Von  Ziemssen  employs  two  large  plate- 
electrodes,  one  anteriorly  between  the  pylorus  and  fundus,  and  the 
other  from  the  fundus  to  spinal  column,  with  a  separating  space 
of  only  2  cm.  The  electrodes  should  be  moistened  and  sufficient 
current  employed  to  cause  strong  contraction  of  the  abdominal 
muscles.  If  smaller  sponges  are  used,  they  can  be  moved  about 
in  these  regions.  The  seance  should  last  ten  to  fifteen  minutes,  and 
be  carried  out  at  first  ever}^  other  day,  depending  upon  indications, 
which  are  the  same  as  for  the  intragastric  method. 

Intragastric  Method. — Kussmaul  first  suggested  the  internal 
application  of  electricity,  and  was  the  first  to  introduce  the  sound 
with  a  copper  wire  and  olive  point  into  the  stomach.  Bardet 
improved  upon  this,  and  employed  an  electrode  which  did  not 
touch  the  stomach  wall,  the  circuit  being  established  by  filling  the 
organ  with  water. 

Numerous  intragastric  electrodes  have  been  devised,  of  which 
the  most  practical  are  Einhorn's,   Lockwood's,  and   Bassler's. 

Lockwood's  Electrode. — This  consists  of  a  very  small  cable  of 
conducting  wire  covered  with  rubber.  The  intragastric  tip  is  oUve 
11 


l62 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


pointed  and  protected  from  the  gastric  mucous  membrane  by  a 
rubber  finistrated  capsule  (Fig.  96).  The  instrument  in  appearance 
is  much  Hke  his  gastrodiaphane.  It  is  easy  of  introduction  and  of 
such  small  caliber  that  it  does  not  incommode  the  patient.  A  glass 
or  two  of  water  is  administered  on  the  empty  stomach,  and  the 
instrument  is  passed  along  the  roof  of  the  mouth,  like  the  stomach- 
tube,  about    18   inches  or,  preferably,  until  the   resistance  of  the 


Fig.  96. — Lockwood's  intragastric  electrode. 

Stomach  wall  is  encountered.  It  is  then  slightly  withdrawn.  The 
outer  end  of  the  instrument  is  furnished  with  a  key  which  is  inserted 
into  the  negative  pole  of  the  battery.  The  sponge  which  is  connected 
to  the  positive  pole  is  applied  over  the  stomach. 

Einhorn's  Deglutible  Electrode. — The  intragastric  tip  is 
similar  in  construction  to  Lockwood's.  The  conducting  wire  is  much 
more  flexible  than  Lockwood's  and  is  covered  with  thin  rubber. 


Fig.  97. — The  deglutible  stomach  electrode. 

It  is  not  introduced  by  the  operator,  but  swallowed  by  the  patient, 
being  similar  in  principle  to  the  stomach  bucket  (Fig.  97). 

The  key  is  connected  to  the  cord  of  the  negative  pole  of  the 
battery.  The  patient  drinks  about  a  glass  of  water.  The  deglutible 
electrode  is  placed  on  the  root  of  the  tongue  and  the  patient  is 
directed  to  swallow  more  water,  which  carries  the  instrument  into 
the  stomach.     A  mark  can  be  placed  on  the  cord,  about  20  inches 


LOCAL  TREATMENT  OF  THE  STOMACH 


163 


from  the  electrode,  to  determine  that  it  has  reached  the  bottom 
of  the  stomach.  The  sponge  is  attached  to  the  positive  pole.  If 
there  is  resistance  to  the  withdrawal  of  the  instrument,  the  patient 
should  swallow  to  relieve  the  spasm. 

Bassler's  Gastric  Electrode. — This  instrument  is  practically 
a  combination  of  Figs.  96  and  97.  It  has  the  usual  capsule  with  a 
cord-like  conducting  wire  and  also  an  introducer  (Fig.  98). 

The  latter  is  withdrawn  after  the  introduction  of  the  electrode. 
After  the  application  is  completed  the  electrode  is  removed  by  the 
flexible  conducting  cord. 

I  have  found  Lockwood's  electrode  easy  to  introduce  and  unob- 
jectionable to  the  patient.     All  are  good  instruments. 

Gastrofaradization. — Duration  ten  to  twelve  minutes.  The 
stomach  electrode  is  attached  to  the  negative  pole.  A  plate  elec- 
trode connected  with  the  positive  pole  is  placed  in  the  epigastric 
region  for  four  or  five  minutes,  and  later  a  sponge.     The  electrode 


Fig.  98. — Bassler's  gastric  electrode. 


is  then  moved  from  left  to  right  several  times  in  the  gastric  region ; 
and  later,  if  marked  constipation,  from  the  caput  coli  to  the  sig- 
moid along  the  colon,  and  also  overthe  umbilical  region.  The  appli- 
catioii  over  the  stomach  occupies  about  two  minutes.  The  electrode 
is  then  placed  to  the  left  of  the  seventh  dorsal  vertebra  for  one  to 
two  minutes,  and  then  returned  to  the  front  for  the  balance  of  the 
time.  The  current  should  be  strong  enough  to  cause  contraction 
of  the  muscles,  but  not  produce  pain.  Application  of  the  sponge  to 
the  intestines  occupies  several  minutes,  in  addition  to  the  ten  minutes 
over  the  stomach.  I  sometimes  reverse  the  poles  during  the  appli- 
cation, by  changing  their  external  attachments  to  the  battery. 

Gastrogalvanization. — Duration  eight  to  ten  minutes.  A  small 
sponge  electrode  is  placed  on  the  epigastrium.  The  intragastric 
electrode  is  connected  with  the  negative  pole.  The  strength  of  the 
current  should  average  15  to  25  milliamperes.  The  full  strength 
is  not  used  at  first.     The  application  is  two  minutes  to  the  epigas- 


1 64  DISEASES   OF  THE   STOMACH  AND   INTESTINES 

trium.  It  is  then  moved  about  over  the  gastric  region  for  three  to  four 
minutes ;  then  for  one  to  two  minutes  in  the  dorsal  region  as  described, 
and  the  balance  of  the  period  in  the  gastric  region. 

There  has  been  some  dispute  as  to  the  effects  of  these  currents 
and  the  indications  for  their  use.  In  general  we  ma}^  sa}'  that  direct 
faradization  increases  the  gastric  secretion,  while  galvanization 
decreases  it. 

Faradization  affects  the  musculature  and  galvanization  the 
sensory  field.  The  claims  regarding  increase  in  absorptive  power 
from  the  use  of  electricity  seem  hardly  to  be  substantiated,  as  it  was 
so  small  as  to  be  wdthin  normal  limits. 

Therapeutics. — The  percutaneous  method  has  proved  of  service 
in  nervous  anorexia  and  in  motor  insufficiency.  The  intragastric 
method  is  preferable  when  possible.  It  renders  some  patients  more 
nervous,  and  in  such  should  be  avoided. 

Among  the  indications  for  gastrofaradization  are:  Atonic 
ectasia,  atony,  relaxation  of  the  cardia  and  pylorus,  and  diminished 
secretion. 


Fig.  99. — Tiirck's  latest  gyromele. 

For  gastrogalvanization  they  are:  Gastralgias,  especially  of 
nervous  type,  ner\-ous  anorexia,  and  hyperacidity. 

Faradization,  however,  has  proved  of  benefit  in  gastric  neuroses. 

Static  Electricity. — This  has  been  recommended  especiall}^  in 
the  atonic  types  of  ectasia,  claim  being  made  that  it  causes  con- 
traction of  the  organ.     In  neuroses  it  is  sometimes  of  service. 

High-frequency  Current. — This  method  is  scarcely  applicable 
by  the  general  practitioner,  but  I  believe  it  of  some  benefit  in  gastric 
neuroses  and  in  atonv. 

Tiirck's  Gyromele. — Turck  has  introduced  this  instrument  for 
the  local  treatment  of  the  stomach  and  colon.  It  consists  of  a  cable 
with  a  sponge  attachment,  which  can  be  made  to  revolve  within  an 
outer  stomach-tube.  There  is  an  arrangement  so  that  medicated 
fluids  can  flow  into  the  stomach  or  colon  through  the  outer  tube, 
and  also  an  attachment  for  a  battery  pole.  He  advocates  its  use  for 
catarrhal  gastritis  to  cleanse  the  mucous  membrane.  It  can  also  be 
employed  alone  for  internal  massage  of  the  stomach  or  combined 
with  electricity.     It  is  depicted  in  Fig.  99. 


CHAPTER   IX 

MASSAGE— VIBRATORY  MASSAGE— HYDROTHERAPY— 
COUNTERIRRITATION— ORTHOPEDIC  APPLIANCES 

MASSAGE 

Massage  of  the  stomach  is  indicated  in  atony  or  in  the  atonic 
form  of  dilatation  and  to  temporarily  aid  in  the  removal  of  gas. 
The  intestines  should  also  be  manipulated  in  these  conditions.  It  is 
of  value  in  stimulating  the  abdominal  muscles  in  gastroptosis.  I  will 
briefly  refer  to  a  few  simple  methods. 

If  massage  is  performed  on  the  absolutely  empty  stomach  it  is 
contracted  and  cannot  be  palpated.  It  is  preferable  to  perform  it 
two  or  three  hours  after  a  meal.  This  aids  in  emptying  the  stomach. 
Earlier  manipulation  might  cause  vomiting. 

Counterindications  are  ulcer,  recent  hemorrhage,  and  acute 
inflammation. 

The  patient  should  be  in  the  dorsal  position;  lower  limbs  flexed. 
The  left  hand  of  the  operator  is  placed  on  the  right  hypochondrium 
to  exert  counterpressure  against  the  pyloric  end.  With  the  thumb 
and  fingers  extended  the  right  hand  performs  stroking  motions  from 
left  to  right  over  the  stomach.  Then  the  stomach  is  kneaded.  These 
procedures  should  alternate.  This  technic  should  be  carried  out 
daily  for  five  to  ten  minutes.  With  dilatation  or  ptosis  of  the 
stomach  the  direction  of  the  stroking  must  be  adapted  to  the  position 
of  the  organ  in  each  case. 

Tapping  (tapotement)  or  rapid  vibratory  movements  with  the 
fingers  can  be  employed.  It  is  often  well  to  rotate  the  patient  to  the 
right  side  during  massage,  so  as  to  aid  in  emptying  the  atonic  stomach. 

VIBRATORY  MASSAGE 

Various  vibrators,  especially  electric,  many  of  which  are  quite 
expensive,  have  been  devised  for  this  purpose.  There  is  an  instru- 
ment run  by  carbonic  acid  gas  pressure.  These  necessitate  the 
electric  current  or  carrying  a  large  tank.  There  is  a  small  portable 
vibrator,  the  Vedee,  manipulated  by  hand  (Fig.  loo),  which  is 
cheap,  simple  of  manipulation,  and  efficacious.  The  strength  of  the 
vibration  is  regulated  by  changing  the  position  of  the  rotating  disk. 
The  instrument  can  be  employed,  with  the  addition  of  electricity, 
by  attaching  a  sponge  arranged  for  battery  connection  and  employ- 
ing the  other  pole  with  a  sponge  over  the  abdomen.  Electric 
vibratory  massage  can  thus  be  given  over  the  stomach  and  intes- 

1G5 


1 66 


DISEASES   OF  THE   STOMACH   AND   INTESTINES 


Fig.  loo.^ — Vedee  vibrator  (new  model). 
tines  (Fig.  loi).     In  addition,  one  battery  pole  can  be  attached  to 


Fig.  loi. — Combined  electricity  and  vibratory  massage. 

the  vibrator  and  the  other  to  the  intragastric  electrode  for  treat- 
ment of  atonv  of  the  stomach. 


VIBRATORY    MASSAGE 


167 


Vibratory  massage  should  be  given  from  left  to  right  over  the 
stomach  for  about  three  minutes,  then  two  minutes  to  the  left  of  the 
seventh  dorsal  vertebra,  and  three  minutes  more  over  the  stomach. 
This  should  be  performed  daily. 

It  is  generally  advisable  to  vibrate  the  intestines,  following 
the  course  of  the  colon,  especially  over  the  sigmoid,  and  also 
over  the  small  intestine.  This  last  can  be  done  before  breakfast 
to  stimulate  the  bowels.  Two  or  three  hours  later  the  stomach 
should  be  vibrated.  The  patient's  family  can  be  taught  to  use 
this  instrument. 


Fig.  102. — Massage  roller  with  demonstration  of  alternating  hot  and  cold 
electric  massage:  a,  Screw  cap;  b,  filling  tube;  c,  funnel  for  filling;  d,  attach- 
ment for  battery  pole. 


Bassler  has  recently  devised  an  excellent  vibrator,  but  it  requires 
the  street  current. 

Massage  Roller. — Various  instruments  have  been  devised,  but 
the  following  is  simple.  It  consists  of  a  revolving  cylinder,  which 
can  be  filled  with  hot  or  cold  water,  and  which  is  furnished  with  a 
battery  attachment.  Heat  or  cold,  or  with  an  instrument  attached 
to   each   battery   pole,   alternating  heat   and   cold,   combined   with 


i68 


DISEASES   OF   THE   STOMACH   AND  INTESTINES 


electricity,  can  be  applied  (Fig.  102).     This  method  can  be  employed 
for  abdominal  massage  in  some  cases  of  chronic  constipation. 


Fig.  103. — Combined  application  of  electricity  and  roller  massage  with  heat. 

I  have  found  the  method  next  depicted  of  some  value  in  stimu- 
lating atonic  conditions  of  the  gastro-intestinal  tract  (Fig.  103). 


LOCAL  HYDROTHERAPY 

Cold. — For  hemorrhage  or  acute  inflammation,  the  ice-bag  is 
preferable  to  the  Leiter  coil.  At  times  it  relieves  ulcer  pain  more 
than  does  heat. 

Priessnitz's  Compress. — A  towel  folded  several  times  is  dipped 
in  cold  or  warm  water,  then  wrung  out,  and  placed  over  the  stomach. 
Oiled  silk  or  gutta-percha  is  placed  over  it,  and  a  flannel  binder 
applied  to  keep  it  in  place.  A  temperature  of  50°  to  75°  F.  or 
warmer  if  desired  can  be  employed. 

This  method  is  of  value  in  nearly  all  painful  diseases  of  the 
stomach.  The  compress  can  be  changed  two  or  three  times  a  day. 
vSome  patients  do  better  with  the  cold,  others  with  the  warm  com- 
press. 


LOCAL   HYDROTHERAPY 


169 


Hot  Applications. — Moist  Heat. — In  cardialgia,  ulcer,  vomiting, 
etc.,  hot  moist  applications  are  of  value.  Poultices  can  be  made  of 
linseed,  flaxseed  or  bran,  boiled  in  water,  or  of  bread  and  milk.  I 
have  seen  hot  meal  or  hot  mashed  potatoes  used  in  country  practice. 

The  poultice  is  wrapped  in  gauze  or  cheese-cloth  and  applied  as 
hot  as  the  patient  can  bear  it.  Fresh  hot  poultices  are  continually 
appHed.  There  is  an  apparatus  which  can  be  boiled  in  water, 
wrapped  in  a  cloth,  and  then  applied  over  the  cataplasm.  Jt  will 
keep  it  constantly  hot. 

A  felt  sponge  dipped  in  boiling  water,  wrung  out,  and  covered 
with  oiled  silk  can  be  employed. 


r--,.     fS."-^i~ii!;6«     i=^-"----^^ 


T!  V 


Sc?iew  cap  oyer  apef/ure 
'f~^     {      ^  forfillin^j. 


ik 


[amp 


Fig.  104. — Continuous  steam  coil  for  the  application  of  heat. 

"Dry  Heat. — The  hot-water  bag,  hot  cloths,  a  light  tin  pieplate 
heated  in  the  oven  and  covered  with  flannel,  the  Japanese  hot  box 
containing  burning  punk,  are  all  useful.  A  continuous  hot-water 
coil  has  been  devised. 

In  the  illustration  (Fig.  104)  is  shown  a  continuous  steam  coil  ^ 
of  my  own.  The  steam  passes  through  a  metal  coil  plate  and  is 
recondensed.  Only  a  small  quantity  of  water  is  necessary  in  the 
boiler.  The  temperature  can  be  regulated  by  the  coverings  of  the 
plate  and  by  the  stop-cocks  on  the  Y-branch  at  the  top  of  the  boiler, 
thus  allowing  less  steam  to  enter  the  coil.     The  coil  can  be  placed 


1  Enteroclysis,  Hypodermoclysis,  and  Infusion,  1900. 


lyo 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


over  a  moist  poultice  to  preserve  its  heat.     In  general,  moist  com- 
presses are  preferable. 

The  fan  douche  and  the  Scotch  douche,  played  over  the  stomach 
region,  alternating  cold  55°  F.  and  warm  95°  F.,  for  about  three 
minutes,  may  have  a  tonic  effect.  Packs,  rubs,  baths,  and  the 
carbonated  bath  are  at  times  employed  for  the  general  tonic  effect. 

COUNTERIRRITATION 

Mustard  and  flour  poultice  (equal  parts) ;  or  black  or  red  pepper, 
3j  (4.0)  to  the  pint  (500  cc.)  of  boiling  water,  flannel  to  be  wet 
therein,  wrung  out,  and  applied  with  an  oil  silk  cover  or  a  turpentine 
stupe,  prepared  by  the  same  method,  are  of  service. 

ORTHOPEDIC  METHODS 

Mechanical  support  of  the  stomach  and  intestines  is  of  great  ser- 
vice. Many  nervous  symptoms  referred  to  the  gastro-intestinal  tract 
can  be  imputed  to  ptosis  of  the  viscera  and  relaxation  of  the  ab- 
dominal walls.  In  simple  atony  of  this  tract  the  proper  support 
frequently  aids  the  bowel  action. 


""^v. 

I 

^--'' 

n 

v 

m 

Fig.  105. — Pattern  for  cutting  the  Rose  plaster  abdominal  binder:  Dotted  lines 

for  section. 


Fig.  106. — Pattern  for  cutting  the  Rose  plaster  abdominal  binder:  Plaster  after 

section. 

The  indications  for  mechanical  support  are  as  follows: 
Ptosis  of  any  or  all  of  the  -viscera  from  any  cause;  atony  of  the 
stomach;  atonic  dilatation  of  the  stomach;  stenotic  ectasia  as  a 
temporary  measure;  atony  of  the  intestines;  pains  from  intra- 
abdominal adhesions  dragging  on  the  viscera ;  hernia  of  the  abdominal 
wall;  after  laparotomy  as  a  temporary  support;  post-partum  to 
prevent  ptosis  (Landau's  disease),  and  also  to  enable  -the  patient 
to  sit  up  in  bed  earlier  and  so  drain  the  uterus.  This  last  was  sug- 
gested by  me  to  Douglas  H.  Stewart,  who  has  reported  successful 
results.  Cases  of  constipation  in  which  atony  is  a  factor.  Pelvic 
disturbances  which  are  associated  with  splanchnoptosis  and  result 


ORTHOPEDIC    METHODS 


171 


from  general  prolapse.  Mucous  colic  in  which  ptosis  is  a  factor. 
Pertdulous  abdomen,  vomiting  of  pertussis  (T.  W.  Kilmer),  sea- 
sickness, and  nervous  vomiting. 

There  are  three  methods:  The  use  of  adhesive  plaster,  the  most 
scientific;  elastic  bandages,  and  a  special  corset. 

To  A.  Rose  we  must  credit  the  best  method  of  adhesive  strapping. 
The  author  first  suggested  the  use  of  zinc  oxid  on  moleskin  plaster, 
from  experiments  finding  it  most  suitable,  and  this  was  adopted  by 
the  originator  of  the  method.  For  a  full  description  I  would  refer 
to  our  work  on  this  subject.^ 


Fig.  107. — Rose's  belt  (under  plaster): 
Step  one. 


Fig.  108. — Rose's  belt:  Step  two,  left 
wing. 


The  method  is  as  follows:  Adhesive  plaster,  zinc  oxid  on  soft 
moleskin  (Johnson  and  Johnson),  preferably  7  inches  wide,  though 
6  inches  can  be  employed.  A  yard  in  length  will  suffice  in  most  cases. 
The  circumference  of  each  patient  should  be  measured,  and  the 
plaster  should  be  long  enough  to  encircle  the  waist.  The  plaster 
is  folded  over  so  that  the  free  ends  are  in  line  and  a  curved  line  drawn 
in  pencil  from  the  lower  margin  of  the  point  where  it  folds  to  the 
free  margin,  to  about  i  inch  below  the  upper  border.  The  plaster  is 
cut  along  this  line,  giving  three  pieces;  or  the  plaster  is  stretched  out 
and  the  dotted  lines  marked,  as  in  Fig.  105,  and  cut  along  these  lines, 
giving  three  pieces,  /  and  the  two  lateral  pieces,  //,  ///,  as  in  Fig.  106. 
^  Rose  and  Kemp,  Atonia  Gastrica. 


172  DISEASES   OF  THE   STOMACH  AND   INTESTINES 


Fig.  109. — Rose's  belt:  Complete. 


Fig.  no. — Dorsal  view:  Under  plaster  with  overlapping  ends  (Rose  and  Kemp). 


ORTHOPEDIC    METHODS 


173 


/  is  applied  to  the  abdomen,  and  the  lateral  pieces,  //,  ///,  over- 
lap in  front  and  are  applied  to  the  under  plaster.  These  serve  to 
draw  up  the  abdomen. 

To  avoid  irritation  of  the  umbilicus,  I  cut  a  V  out  of  the  upper 
border  of  the  under  plaster  or  invert  a  small  portion  of  it.  The  sharp 
angle  below  should  be  cut  off  to  avoid  interference  with  the  pubic 
hair.  The  curved  portions  of  the  lateral  wings  should  look  upward 
and  somewhat  inward  and  adhere  to  the  lower  ribs.     The  sharp 


Fig: 


-Dorsal  view:  Plaster  dressing  complete  (Rose  and  Kemp). 


angles  of  the  lateral  wings  at  the  symphysis  may  also  be  cut  off  to 
avoid  the  hair. 

Hair,  if  present  on  the  abdomen,  is  shaved  and  the  surface 
cleaned  with  ether  or  chloroform. 

The  plaster  is  applied  with  the  patient  in  the  dorsal  position, 
and  preferably  with  hips  slightly  elevated. 

In  the  illustrations  (Figs.  107-109)  are  shown  the  three  stages 
of  application  of  the  belt,  the  under  plaster,  one  wing  applied, 
and  the  complete  contrivance.  In  Figs,  no  and  in  are  shown  the 
rear  view  during  application. 


174 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


The  plaster  should  remain  on  for  four  to  six  weeks,  depending  on 
the  season  of  the  year,  irritation  (which  is  rare),  or  its  loosening. 


Fig.  112. — Application  of  narrow  strips       I'ig.  113. — Application  of  plaster:  Sec- 
of  adhesive  plaster:  First  step.  ond  step. 

It  should  then  be  removed,  a  full  bath  given,  talcum  dusted  on,  and 
twenty-four  hours  later  a  new  belt  applied. 


Fig.  114. — Application  completed. 

One  patient  sent  me  by  Wm.  H.  Thomson,  a  severe  case  of 
splanchnoptosis,  wore  the  belt  fourteen  months,  gained  40  lbs.  in 
weight,  and  was  completely  cured. 


ORTHOPEDIC    METHODS 


175 


The  device  gives  brilliant  results.  The  method  of  support  by  a 
pad  for  the  special  organ  is  unscientific. 

Only  on  occasions  when  the  material  for  Rose's  belt  was  not  at 
hand  have  I  applied  a  method  with  narrow  strips  of  plaster,  as 
depicted  in  Figs.  11 2-1 14.  They  overlap  at  the  linea  alba  in  front 
and  at  the  spine  behind.  As  the  final  procedure,  two  transverse 
strips  are  applied  in  front. 

Rosewater  Adhesive  Belt. — A  strip  of  zinc  oxid  plaster  of 
sufficient  length  and  two  to  three  inches  wide  is  fastened  to  the 
abdomen  just  above  the  pubes.  This  is  drawn  upon  upward  and 
fastened  above  to  the  lower  end  of  the  sternum.     Diagonal  strips 


Fig.  115- 


-Front  view:  Step  one. 


Fi?.  116. — Rear  view. 


Fig.  117. — Front  view.     Belt  complete. 
Figs.  1 1 5-1 17. — Rosewater  adhesive  plaster  belt  (Rose  and  Kemp). 

crossing  the  lower  end  of  the  vertical  strip,  overlapping  behind  at 
the  spine,  are  then  applied  (Figs.  115  and  116). 

A  horizontal  strip  is  fastened  to  one  hip  and  stretched  across  the 
pubes  to  the  other  hip,  overlapping  the  ends  of  the  other  plaster 
and  acting  as  an  additional  girdle  (Fig.  117). 

Plaster  strapping  affords  continuous  support  during  treatment, 
which  other  methods  do  not.  Numerous  modifications  have  been 
devised,  but  these  are  the  most  practical. 

Kihner's  Abdominal  Belt. — An  ingenious  belt  was  devised  some 
years  ago  by  T.  W.  Kilmer  for  the  relief  of  vomiting  in  pertussis. 
The  original  instrument  consisted  of  a   stockinet   band  apphed  as 


176 


DISEASES   OF   THE    STOMACH   AND    INTESTINES 


Fig.  ii8. — Kilmer's  belt  stockinet  band:  Step  one. 


Fig.  119. — Kilmer's  belt  (complete):  Elastic  %vebbing,  front. 


ORTHOPEDIC    METHODS 


177 


in  Fig.  118.     Around  this  was  wound  a  strip  of  silk  elastic  webbing, 
which  could  be  pinned  or  sewed  on,  as  in  Figs.  119  and  120. 


Fig.  120. — Kilmer's  belt  (complete):    Elastic  webbing,  rear. 

The  apparatus  extends  from  just  above  the  hips  and  symphysis 
well  up  on  the  thorax.  The  relief  of  vomiting  and  cough  was  quite 
remarkable  in  pertussis. 


12 


178 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


Fig.  121. — Improved  belt  (front). 


Fig.  122. — Improved  belt  (rear). 


ORTHOPEDIC    METHODS 


179 


Recently  Kilmer  reports  a  simplified  belt^  made  of  linen,  with 
strips  of  elastic  webbing  inserted  on  either  side.  It  laces  up  the 
back  (Figs.  121  and  122). 

The  belt  should  measure  slightly  less  (2  to  3  inches)  than  the 
circumference  at  the  navel.     The  degree  of  constriction  should  be 


\ 

\ 

^^..^ 

jS=^f== 

^    x 

""Wi 

¥n 

m 

vd\l 

l|L 

AU 

Q| 

P 

'  B-^ "_ 

•«r^^ 

! 

t 

>      '     ' 

Fig.  123. — Teufel's  abdominal  supporter. 

determined  in  every  case.  The  instrument  is  valuable  for  the 
prevention  of  seasickness,  for  nervous  vomiting,  and  as  an  abdominal 
support.     The  cost  is  shght. 

Silk  Elastic  Belts. — Various  types  of  silk  elastic  belts  are 
employed.  Figs.  123-125  show  useful  instruments.  Storm's  abdom- 
inal supporter  is  also  excellent. 


\ 


V 


Fig.  124. — ^Abdominal  supporter. 


Fig.  125. — Abdominal  supporter. 


Special  Corsets. — The  most  valuable  support  of  this  type  is 
that  of  E.  Gallant,  which  is  depicted  under  Gastroptosis.  The  La 
Grecque  surgical  corset  is  also  useful,  and  is  illustrated  in  the  same 
chapter  (Fig.  161). 

^  Archives  of  Pediatrics,  February,  1907 


CHAPTER  X 
CATARRH  OF  THE  STOMACH 

ACUTE  AND  CHRONIC  GASTRITIS 

Acute  gastritis 

Acute  gastritis  may  be  defined  as  an  acute  inflammation  of  the 
gastric  mucous  membrane  with  resulting  disturbances  of  digestion. 
It  is  of  different  degrees  of  severity,  being  Hmited  to  the  superficial 
layer  of  the  mucous  membrane,  or  it  may  extend  to  the  glandular 
p'arenchvma  or  involve  the  interstitial  tissues. 

It  is  subdivided  into  simple  acute  gastritis,  toxic  gastritis,  and 
phlegmonous  gastritis. 

SIMPLE  ACUTE  GASTRITIS 

{Synonyms . — Acute  Gastric  Catarrh;  Acute  Gastric  Dyspepsia.) 

Etiology. — Simple  acute  gastric  catarrh  is  one  of  the  most 
frequent  diseases  met  with  by  physicians.  It  occurs  in  all  classes 
of  society  and  at  all  ages.  It  may  be  primary  or  secondar}^  to 
another  disease.  One  of  its  frequent  causes  is  some  irritant, 
mechanic,  chemic,  or  thermal;  thus  errors  in  diet,  or  too  large  a 
quantity  of  food  that  has  been  imperfectly  masticated,  or  rapidly 
bolted;  too  hot  or  too  cold  food  or  drink;  too  highly  spiced  or  fer- 
mented foods;  rancid  butter;  unripe  or  spoiled  fruit;  spoiled  food  or 
drink,  or  overindulgence  in  alcohol. 

Fermentation  or  putrefaction  are  most  apt  to  occur  in  food  during 
the  summer,  and  these  factors  probably  account  for  the  epidemics 
occurring  at  that  season,  though  infection  has  been  suggested.  Such 
cases  generally  occur  as  gastro-enteritis. 

Bacterial  infection  of  food  may  be  a  cause,  as  the  colon  bacillus 
in  milk,  or  meat,  or  sausage  poisoning. 

Primary  mycosis  of  the  stomach,  the  favus  fungus;  schizomvcetes ; 
parasites,  as  the  larvae  of  flies;  ascarides,  oxyuris  and  taenia,  by 
entering  the  stomach,  and  abdominal  burns  are  rare  causes.  Acute 
catarrhal  or  suppurative  conditions  of  the  nose  and  throat  may 
produce  acute  gastritis  from  the  ingestion  of  discharges.  I  have 
recently  seen  one  such  case  and  the  patient  suffering  from  acute 
gastritis,  cured  by  treatment  of  the  source. 

Some  persons  have  a  predisposition  to  a  "weak  stomach,"  and 
this  condition  seems  almost  to  be  hereditary.  Others  have  been 
trained  to  such  a  simple  diet,  as  the  children  of  dyspeptics,  that  the 

180 


CATARRH  OF  THE  STOMACH  l8l 

stomach  cannot  perform  its  normal  amount  of  work  and  readily 
becomes  irritated.  In  old  persons,  invalids,  or  anemic  women  the 
organ  is  readily  affected. 

Acute  gastritis  may  be  secondary  to  the  acute  infectious  diseases, 
such  as  measles,  typhoid,  variola,  pnuemonia,  etc.,  or  as  a  sequel  of 
acute  nephritis.     I  have  seen  an  attack  follow  prolonged  anesthesia. 

A  diphtheritic  or  membranous  gastritis  has  been  met  with  in 
diphtheria,  or  as  a  secondary  process  in  typhoid,  typhus,  pneumonia, 
etc.     It  cannot  be  diagnosed  unless  the  membranes  are  vomited. 

Morbid  Anatomy. — Acute  gastritis  is  characterized  by  an  acute 
inflammation  of  the  superficial  layers  of  the  mucosa,  with  an  increased 
secretion  of  mucus  and  a  desquamation  of  the  epithelial  cells. 

The  mucous  membrane  is  reddened  and  swollen,  less  gastric 
juice  is  secreted,  and  mucus  covers  the  surface.  The  swelling  is 
diffuse  or  in  circumscribed  areas.  There  are  sometimes  slight 
hemorrhages  and  small  erosions  or  sacculations  of  the  mucous 
membrane.  The  submucosa  may  be  edematous.  The  pyloric  end 
is  more  frequently  affected.  Gastric  secretion  is  weakly  acid,  neutral, 
or  even  alkaline  and  diminished  in  quantity.  Beaumont,  from  his 
observations  on  St.  Martin,  has  given  an  excellent  description. 

Microscopic. — The  superficial  epithelial  layer  is  partially 
loosened  or  in  a  condition  of  cloudy  swelling.  The  parietal  and 
principal  cells  cannot  be  distinguished  apart;  they  are  granular  and 
in  a  condition  of  cloudy  swelling  and  fatty  degeneration,  and  are 
shrunken.  The  capillaries  are  dilated  and  round  cells  are  found  in  the 
interglandular  tissue,  between  the  epithelial  cells  and  on  the  surface. 
Karyokinesis  may  be  present. 

Symptoms. — These  vary  according  to  the  severity  of  the  attack. 
There  is  loss  of  appetite,  discomfort,  fulness  or  pressure  in  the  region 
of  the  stomach,  belching  of  gas,  which  may  taste  sour,  and  occasional 
nausea.  In  some  cases  there  are  no  rise  of  temperature  and  no 
vomiting,  and  the  symptoms  pass  off  in  a  da}'  or  two;  the  bowels 
are  costive  or  diarrhea  is  present. 

In  more  severe  cases  there  are  pains  in  the  gastric  region,  head- 
ache, nausea,  vomiting  (prolonged  and  excessive),  first  of  food,  then 
chiefly  of  mucus,  at  times  streaked  with  blood,  and  frequently  bilious 
vomiting.  There  may  be  considerable  prostration.  Often  there  is 
an  acid  taste  in  the  mouth.  There  is  generally  a  temperature, 
sometimes  rising  to  102°  to  104°  F.,  and  at  times  chills,  and  the 
tongue  is  usually  coated  and  swollen.  The  pulse  is  frequently  rapid 
and  feeble. 

In  the  cases  due  to  ingestion  of  spoiled  food,  etc.,  auto-intoxi- 
cation undoubtedly  results  and  aggravates  the  symptoms. 

Vomiting  usually  follows  the  introduction  of  the  irritant,  but  is 
sometimes  delayed  for  some  hours,  and  food  is  found  that  was 
ingested  twelve  or  fifteen  hours  before,  a  condition  of  acute  motor 
insufficiency.     Constipation    or    diarrhea    is    present.     The    early 


l82  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

vomitus  often  has  a  disagreeable  odor  and  contains  food  remnants. 
The  reaction  is  sHghtly  acid  and  free  hydrochloric  acid  is  often 
absent.  Lactic  and  other  organic  acids  are  at  times  present.  Occa- 
sionally a  duodenitis  with  jaundice  is  associated.  Herpes  labialis  is 
quite  frequent. 

Physical  Examination. — The  region  of  the  stomach  is  usually 
distended  and  sensitive,  and  may  be  tender  on  pressure. 

Urine  is  scanty,  dark  in  color,  of  high  specific  gravity,  urates 
marked,  and  occasionally  indican  and  albumin. 

Duration. — This  is  usually  short,  from  two  to  three  days,  though 
at  times  prolonged  to  a  week. 

Diagnosis. — Some  of  the  infectious  diseases,  notably  scarlatina, 
begin  like  the  febrile  form  of  acute  gastritis,  and  one  should  always 
be  on  the  watch  for  such  an  occurrence. 

In  rare  cases  the  symptoms  are  intensely  severe,  headache  and 
even  delirium  being  so  marked  as  to  have  been  mistaken  for  rAen- 
ingitis.  In  the  latter  case,  Kernig's  sign  can  be  elicited. and  lumbar 
puncture  is  an  aid  to  diagnosis. 

In  biliary  coHc,  with  acute  vomiting,  the  pain  radiates  to  the 
right  side  or  right  shoulder,  and  pain  over  the  gall-bladder  is  present. 

In  cholecvstitis,  with  or  without  calculi,  with  Uttle  or  no  pain 
and  no  jaundice,^  but  vomiting,  the  diagnosis  is  more  difficult.  The 
previous  history,  tenderness  over  the  gall-bladder,  and  the  presence 
of  leukoc\i:osis,  especially  the  increase  in  the  polynuclears,  are 
significant.     Hyperchlorhydria  is  frequently  associated. 

With  peritonitis,  we  have  muscular  rigidity,  leukoc^iiosis,  in- 
creased polynuclears,  marked  abdominal  tenderness,  and  distention. 

With  ner^^ous  gastralgia,  the  material  vomited  is  very  acid 
(hyperchlorhydria),  no  mucus,  and  the  nervous  history. 

Y\'ith  typhoid  fever,  we  have  the  gradual  rise  of  temperature, 
increasing  daily,  the  splenic  enlargement,  frequently  the  eruption, 
often  bronchitis,  EhrHch's  diazo  and  the  Widal  reactions;  while, 
with  acute  gastritis,  the  rise  of  temperature  is  sudden  and  the  fall 
equally  sudden,  and  there  is  the  absence  of  splenic  enlargement 
and  other  symptoms. 

When  jaundice  is  associated  with  acute  gastritis,  the  duodenum 
has  evidently  become  involved.  The  gastric  crises  of  locomotor 
ataxia  have  been  mistaken  for  acute  gastritis,  but  the  absence  of 
knee-jerks,  the  Romberg  symptom,  and  Argyll-Robertson  pupil  are 
diagnostic  of  tabes. 

Prognosis. — This  is  favorable,  except  in  very  old  people  and 
invalids. 

Treatment. — Prophylaxis. — In  patients  subject  to  attacks  of 
acute  gastritis,  excess  in  eating,  rich  food,  lobster,  food  and  drink 
that  are  too  hot  or  cold,  or  any  articles  for  which  they  have  an 
idiosyncrasy  should  be  forbidden.     Candy  and  cake  should  not  be 

1  The  presence  of  Head's  gall-bladder  zone  of  cutaneous  algesia  aids  diagnosis. 


CATARRH  OF  THE  STOMACH  1 83 

allowed.  Unripe  and  dirty  fruit  should  be  avoided.  With  infants, 
care  should  be  taken  as  to  the  storage  of  milk  and  its  preparation. 

If  the  acute  gastritis  be  due  to  ingestion  of  improper  food,  there 
are  two  principles  to  follow:  Clear  out  the  gastro-intestinal  tract 
and  give  rest  to  the  stomach.  If  there  are  other  factors,  the  first 
consideration  does  not  apply.  In  all  cases  rest  in  bed  should  be 
enjoined. 

In  the  mild  cases,  with  nausea  but  no  vomiting,  castor  oil,  oj  to 
iss  (32.0-48.0) ;  or,  if  there  is  doubt  of  this  being  retained,  then 
calomel,  gr.  2  to  5  (0.125-0.3),  or  blue  mass,  gr.  5  (0.3),  followed  in 
twelve  hours  by  a  saline,  such  as  a  wineglass  of  apenta,  or  citrate 
of  magnesia  (wineglass),  or  magnesia  sulph.,  5j  to  ij  (4.0-8.0), 
should  be  administered. 

If  much  nausea,  calomel,  gr.  -jV  (0.006),  with  sodium  bicarb., 
gr.  h  (0.0325),  every  hour  for  eight  or  ten  doses,  followed  by  a  saline. 

Children  should  receive  proportionately  small  doses  of  cathartics. 

For  eructation  of  acid  fluid  (pyrosis),  bismuth  subnit.,  gr.  3 
(0.2),  with  sodium  bicarb.,  gr.  3  (0.2),  every  hour  or  two;  or  magnesia 
usta,  oss  (16.0),  with  sodium  bicarb.,  oSS  (16.0),  as  much  as  covers 
the  point  of  a  knife,  every  three  hours. 

For  nausea  or  vomiting,  oxalate  of  cerium,  gr.  i  (0.065),  every 
hour  for  several  doses,  or  bismuth  subnit.,  gr.  2  to  4  (0.125-0.25), 
alone,  or  with  sodium  bicarb.,  same  dose;  or  gelatin  (i  per  cent,  solu- 
tion), dose  oj  (4-o),  every  hour,  given  cold;  or  milk,  oviij  (250.0  cc), 
with  oxalate  cerium,  gr.  10  (0.6),  and  sodium  bicarb.,  gr.  10  (0.6), 
packed  in  ice;  dose,  5j  (4-0)  every  hour;  or  Fowler's  solution  of 
arsenic,  HXj  (0.06),  every  hour  for  four  doses,  are  of  value. 

Teaspoonful  doses  of  hot  water  or,  occasionally,  a  piece  of  cracked 
ice;  or  white  of  raw  egg  beaten  up  and  given  cold  in  i-dram  doses 
(4.0),  every  half -hour  to  an  hour,  are  useful. 

Cocain,  carbolic  acid,  or  creosote  I  strongly  deprecate.  Heat  should 
be  applied. 

Application  of  Heat. — A  hot-water  bag,  one-third  full  to  avoid 
weight ;  a  Japanese  hot  box,  a  hght  hot  salt-bag,  a  thin  tin  pieplate 
heated  in  the  oven  and  covered  with  flannel ;  or  moist  heat  by  means 
of  a' flaxseed  poultice,  hot  mashed  potato  or  bread  poultice  in  country 
practice ;  mustard  and  flour  poultice  (equal  parts) ;  or  black  or 
red  pepper  poultice— 5j  (4.0)  to  Oj  (500  cc.)  of  boiUng  water — 
and  wring  out  flannel  in  the  same  and  apply,  covering  with  oiled 
silk. 

If  the  discomfort  is  marked,  then  give  warm  salt  water,  oss 
(2.0)  of  salt  to  oviij  (250  cc.)  of  water,  and  tickle  the  fauces  to 
promote  vomiting,  or  lavage. 

Small  doses  of  hot  water  may  be  given  to  relieve  thirst  and  food 
should  be  avoided  for  twenty-four  hours. 

If  small  quantities  of  nourishment  be  given,  I  have  found  §j 
(32.0)  doses  every  hour  of  a  5  per  cent,  gelatin  solution  (in  a  glass 


184  DISEASES   OF  THE   STOMACH  AND  INTESTINES 

packed  in  ice)  of  special  value,  or  small  quantities  of  milk  and  lime- 
water  (equal  parts),  or  peptonized  milk  or  kumyss. 

In  severer  cases,  the  stomach  should  be  emptied,  preferably  by 
lavage,  §j  to  ij  (32.0-64.0)  of  Phillips'  milk  of  magnesia  to  2 
quarts  (liters)  of  warm  water  being  excellent  for  this  purpose. 
Plain  warm  water  or  normal  salt  solution  may  be  employed. 

I  frequently  administer  calomel,  gr.  3  to  5  (0.2-0.3),  ^nd  sodium 
bicarb.,  gr.  5  (0.3),  in  a  little  water,  through  the  stomach-tube  after 
lavage  before  withdrawal  of  the  tube.  This  is  generally  retained, 
with  resulting  thorough  clearing  of  the  bowels.  Saline  solution 
should  not  be  employed  for  lavage  if  calomel  is  thus  given. 

Later  an  enema  of  saturated  solution — oij  to  iij  (64.0-96.0) — 
of  magnesium  sulphate,  or  a  recurrent  enteroclysis  with  normal 
saline  solution  at  110°  F.  should  be  administered  (several  quarts — 
liters),  or  a  soapsuds  enema,  i  quart  (liter),  containing  olive  oil, 
§vj  (200  cc),  may  be  substituted.  Even  if  the  calomel  be  omitted, 
it  is  of  great  importance  to  move  the  bowels.  If  the  case  is  not  due 
to  ingestion  of  irritating  food,  then  bismuth  subnitrate,  oxalate  of 
cerium,  a  few  doses  of  gr.  75  (0.006)  of  calomel  every  hour,  sodium 
bicarb.,  etc.,  may  be  tried  for  a  brief  period;  and  if  these  fail,  lavage 
should  be  performed.  Gelatin  solution  or  white  of  egg  often  are  of 
value  in  such  cases. 

With  bilious  vomiting,  lavage  should  be  employed  at  once,  as 
there  is  practically  reversed  peristalsis  with  an  open  pylorus,  and 
the  continuous  accumulation  of  bile  in  the  inflamed  stomach  keeps 
up  the  vomiting.  Enteroclysis  should  be  used  after  lavage  (within 
one  hour)  to  promote  normal  peristalsis. 

It  may  be  necessary  to  wash  the  stomach  several  times,  but  it  is 
the  best  method  to  check  vomiting. 

In  the  severe  cases,  due  to  ingestion  of  improper  food,  it  is  my 
opinion  that  calomel  should  be  given  directly  after  lavage,  even 
though  some  of  it  be  vomited,  as  auto-intoxication  is  a  factor. 

In  addition  to  the  milk  of  magnesia,  if  the  vomitus  is  very  foul, 
I  add  gr.  10  (0.6)  resorcin  to  the  fluid  for  lavage  and  wash  with  the 
patient  both  in  the  erect  and  lying-down  position.  I  do  not  care 
for  apormorphin,  gr.  ^  (0.006),  ipecac,  or  tartar  emetic  to  empty 
the  stomach. 

If  there  is  considerable  prostration,  enemata  of  hot  normal  salt 
solution  (115°  F.)  and  strychnin  by  hypodermic — gr.  gV  to  -gV 
(0.00108-0.002) — may  be  necessary. 

In  rare  cases,  when  there  has  been  much  vomiting  and  the  patient 
is  exhausted,  codein,  gr.  |  to  \  (0.008-0.016),  by  hypodermic,  or 
the  same  amount  of  morphin  may  be  used.  I  sometimes. employ  a 
single  dose  after  lavage  to  quiet  the  patient.  A  suppository — 
gr.  I  (0.064)  opium,  or  gr.  \  (0.016)  morphin  with  gr.  -Jr  (0.021) 
extract  belladonna — may  be  substituted. 

Diet. — Entire  abstinence  from  food  during  the  first  twent3^-four 


CATARRH    OF   THE   STOMACH  1 85 

hours  or  longer  is  preferable;  nutritive  enemata  may  be  given  and 
injections  (rectal)  of  hot  saline  solution  to  relieve  thirst.* 

For  the  latter,  oj  (4.0)  doses  of  hot  water  by  mouth,  or  of  a  cold 
I  to  2  per  cent,  gelatin  solution  are  preferable  to  cracked  ice.  The 
gelatin  seems  to  have  an  excellent  effect. 

Later  small  doses  of  cold  gelatin  (5  per  cent,  solution)  or  milk 
and  lime-water  (equal  parts)  can  be  given,  or  milk,  oviij  (250  cc), 
with  sodium  bicarb.,  gr.  10  (0.6),  and  oxalate  cerium,  gr.  10  (0.6), 
in  oss  to  j  (16.0-32.0)  doses,  given  cold,  every  two  or  three  hours. 

White  of  egg  beaten  up  and  given  cold ;  barley-water  alone  or  with 
milk  (equal  parts) ;  rice  gruel,  very  thin,  made  from  rice  flour  (Park 
and  Tilford)  with  milk  may  be  added. 

Later  add  eggs  (soft  boiled),  scraped  raw  beef,  pigeon  (boiled), 
calves'  brains,  zwieback,  broths,  soups,  bouillon,  boiled  chicken,  and 
gradually  increase  to  full  diet. 

If  after  the  acute  attack  has  subsided  the  patient  suffer  from  a 
feeling  of  pressure  and  discomfort,  dilute  hydrochloric  acid  may  be 
given  to  aid  digestion. 

I^.    Acid,  hydrochlor.   dilut oiiss  (lo.o) ; 

Aq.  destil q.  s.  ad.    oij  (60.0). 

Sig. —  oj  to  ij  (4.0-8.0),  in  water,  t.  i.  d. 

The  same  combined  with  small  doses  of  tincture  of  nux  vomica, 
TTLv  (0.3)  in  each  dose;  or  with  compound  tincture  cinchona,  lUx  (0.6) 
in  each  dose  may  be  given. 

These  remedies  should  be  administered  one-half  hour  after  meals 
or  the  same  time  before. 

TOXIC  GASTRITIS 

Etiology. — This  most  intense  form  of  inflammation  of  the 
stomach  is  caused  by  the  swallowing  of  concentrated  mineral  acids 
or  strong  alkalis,  or  by  poisons,  such  as  phosphorus  or  arsenic. 
Among  such  are  nitric,  sulphuric,  hydrochloric,  oxalic,  and  carbolic 
acids;  the  caustic  alkalis,  as  caustic  potash,  caustic  soda,  soap  lees, 
and  strong  ammonia;  alcohol,  phosphorus,  arsenic,  potassium  cyanid, 
corrosive  sublimate,  and  potassium  chlorate.  The  effects  are  more 
severe  on  the  empty  stomach. 

Anatomy. — The  acids  and  alkalis  destroy  the  parts  they  come 
in  contact  with,  causing  various  degrees  of  sloughing  of  the  mucous 
membrane.  They  may  penetrate  the  submucosa  or  the  entire  stomach 
wall  and  produce  perforative  peritonitis. 

Alcohol,  phosphorus,  or  arsenic  cause  an  acute  inflammation  of 
severe  type,  the  mucous  membrane  becoming  swollen  and  super- 
ficially necrotic,  with  hemorrhagic  spots  in  the  submucosa,  and 
there  is  fatty  degeneration  of  the  epithelia  of  the  glandular  tubuli. 

Symptoms. — There  are  intense  pain  in  the  gastric  region,  violent 
and  burning  in  character,  and  increased  on  pressure;  and  frequently 
1  Proctoclysis  is  also  excellent. 


1 86  DISEASES   OP  THE   STOMACH  AND   INTESTINES 

pain  in  the  pharynx  and  esophagus  (along  the  sternum).  There 
are  saHvation,  difficulty  in  swallowing,  and  usually  vomiting,  con- 
stant and  repeated,  which  fails  to  relieve  the  pain.  This  is  generally 
immediate,  though  not  always  so.  There  may  be  food  remnants 
in  the  vomit,  mucus,  streaks  of  blood,  and  even  shreds  of  mucous 
membrane.  The  abdomen  is  tender,  at  times  distended,  though 
occasionally  contracted.  Symptoms  of  collapse  often  appear,  the 
face  pale  and  anxious,  the  skin  pale  and  extremely  cold,  pulse  rapid 
and  feeble,  respiration  rapid  and  shallow.  There  are  restlessness 
and  sometimes  convulsions. 

Albumin  and  blood  often  are  present  in  the  urine  and  petechias 
under  the  skin.  Peritonitis,  shock,  or  respiratory  or  cardiac  failure 
may  cause  the  fatal  issue. 

Some  cases  are  more  protracted.  There  may  be  jaundice  or 
hematuria,  or  intestinal  ulceration,  or  degeneration  of  the  liver  or 
kidneys.  Phosphorus-poisoning  may  produce  hemorrhagic  jaundice 
and  symptoms  simulating  acute  yellow  atrophy  of  the  liver. 

Stricture  of  the  esophagus,  pylorus,  or  cardiac  orifice  of  the 
stomach  can  result  from  the  damaged  mucous  membrane,  with 
corresponding  symptoms,  such  as  dilatation  of  the  stomach,  etc. 
In  rare  cases,  atrophy  of  the  mucous  membrane  (achylia  gastrica) 
follows,  or  hour-glass  stomach,  or  perigastric  adhesions. 

Diagnosis  is  usually  easy.  The  sudden  appearance  of  violent  gas- 
tric symptoms  in  a  perfectly  healthy  subject  should  excite  suspicion. 

Inspection  of  the  lips,  mouth,  and  tongue  will  show  the  effect  of 
corrosive  poison,  if  such  have  been  taken,  and  examination  of  the 
vomitus  and  odor  of  the  breath  may  afford  information.  Inspection, 
if  possible,  of  the  receptacle  from  which  the  substance  was  taken, 
and  examination  of  the  latter,  if  any  remain,  are  important.  The 
patient  often  gives  a  clear  history. 

Prognosis. — It  is  best  to  give  a  guarded  prognosis  even  in  appar- 
ently favorable  cases. 

Treatment. — There  are  certain  cardinal  rules  to  follow  in  the  treat- 
ment of  toxic  gastritis:  first,  administer  fluid  to  dilute  the  poison, 
and  at  the  same  time  give  an  antidote ;  empty  the  stomach  as  rapidly 
as  possible,  preferably  by  lavage ;  administer  demulcents ;  stimulate 
the  patient  and  give  a  cathartic  to  clear  the  poison  from  the  bowels. 

Though  some  advise  against  lavage  in  poisoning  from  acids  and 
alkalis  for  fear  of  perforating  the  stomach,  there  is  far  greater  danger 
of  perforation  by  leaving  the  poison  in  the  organ,  with  the  additional 
risk  of  cardiac  or  respiratory  failure,  or  subsequent  damage  to  the 
intestines  or  other  viscera. 

lyavage  by  siphonage  of  the  stomach  is  indicated  in  all  cases  of 
poisoning.  Warm  water  at  about  101°  F.  should  be  employed  and 
the  organ  washed  until  thoroughly  clean.  Any  bland  fluid,  such  as 
tea,  coffee,  soup,  water,  or  milk,  can  be  used  in  an  emergency  to  dilute 
the  poison  and  wash  the  stomach. 


CATARRH  OF  THE  STOMACH  187 

A  gastric  siphon  can  be  improvised  from  a  fountain  syringe  by 
removing  the  tip  and  clip  and  rounding  the  edges  of  the  extremity; 
or  from  a  kitchen  funnel  and  rubber  tube  of  small  caliber. 

If  lavage  be  impossible,  then  give  a  pint  of  lukewarm  water  with 
5ij  (8.0)  of  mustard  dissolved  therein,  or  warm  salt  water  and 
tickle  the  fauces  with  the  finger  or  a  feather. 

Apomorphin,  gr.  xV  (0.006),  by  hypodermic;  zinc  sulphate, 
gr.  30  (2.0),  in  oiv  (30.0)  of  water;  copper  sulphate,  gr.  5  (0.3), 
providing  these  latter  were  not  the  poisons  ingested;  or  syrup  of 
ipecac,  oj  to  iij  (4.0-12.0),  can  be  employed. 

Among  useful  demulcents  are  whites  of  raw  eggs,  milk,  olive  oil, 
barley-water,  flour  boiled  with  water,  and  gum-arabic  water.  Fats 
and  oils  should  be  avoided  in  phosphorus-poisoning.  The  subsequent 
treatment  is  of  acute  gastritis,  enteritis,  and  of  special  symptoms. 

Antidotes. — For  Acid  Poisoning. — Alkalis,^  such  as  calcined 
magnesia;  powdered  chalk  in  water;  sodium  carbonate  (w^ashing 
soda),  dilute;  potassium  cabonate;  sodium  or  magnesium  sulphate, 
Bss  (16.0),  in  water;  Carlsbad  salts;  soapsuds  in  water. 

For  Carbolic  Acid. — Alcohol  (95  per  cent.),  oj  to  iij  (32.0-96.0); 
raw  whisky  or  brandy,  or  liquor  with  a  large  percentage  of  alcohol. 
The  alkalis  can  be  used  subsequently  or  alone  if  alcohol  or  liquors 
are  not  obtainable. 

For  Caustic  Alkalis. — Dilute  acids,  such  as  dilute  vinegar  or  lemon 
juice;  tartaric  or  citric  acid. 

For  Tartar  Emetic  and  Antimony  and  its  Compounds. — Tannic  acid 
or  strong  tea. 

For  Arsenic  and  its  Compounds. — ^Tincture  of  perchlorid  of  iron, 
§iss  (48.0)  in  a  wineglass  of  water,  add  Bss  (16.0)  sodium  carbonate 
(washing  soda)  in  half-tumbler  of  water,  mix,  and  administer. 
This  renders  insoluble  about  gr.  5  (0.3)  of  arsenic.  Repeat  dose, 
or  give  dialyzed  iron,  tablespoonful  doses. 

For  Copper  Salts. — Potassium  ferrocyanid,  5j  (4.0)  to  oiv  (125  cc.) 
of  water,  forms  insoluble  copper  cyanid. 

For  lodin,  lodids,  and  Iodoform. — Starch  solution  in  cold  water; 
sodiutn  bicarbonate;  lead  acetate,  5ij  (8.0)  in  oiv  (125  cc.)  of  water. 

For  Lead  and  its  Salts. — Magnesium  or  sodium  sulphate,  or 
dilute  sulphuric  acid,  Tri30  (2.0),  in  water. 

For  Mercury  and  its  Salts  {Corrosive  Sublimate,  etc.). — White  of 
raw  egg;  milk;  form  albuminate. 

For  Silver  Nitrate. — Salt  solution. 

For  Zinc  Salts. — Sodium  or  potassium  carbonate;  tannic  acid; 
tea;  white  of  egg;  milk. 

For  Phosphorus  (Rat  Paste,  Matches).— Copper  sulphate,  gr.  3 
to  5  (0.2-0.3),  in  oiv  (125  cc.)  of  water,  a  number  of  doses;  forms 
insoluble  phosphid  of  copper  and  acts  as  an  emetic;  old  French 

1  Soda  bicarbonate,  oj  (16.0),  or  plaster  scraped  from  the  wall,  dissolved  in 
water  oviij  (250  cc.)  can  be  employed. 


1 88  DISEASES   OF  THE   STOMACH  AND  INTESTINES 

turpentine.  Avoid  oils,  fats,  milk,  and  yolks  of  eggs.  Avoid 
American  or  German  turpentine. 

For  Alcohol. — Ammonium  carbonate,  gr.  3  (0.2),  in  water. 

The  stomach  should  receive  rest  after  immediate  treatment. 
Pain  may  be  relieved  by  local  heat,  or  codein  or  morphin,  gr.  i  to  J 
(o.oo8-o!^oi6),hypodermically.  Large  doses  of  bismuth  subnitrate 
may  be  given  if  the  bowels  continue  irritable.  Retention  or  sup- 
pression of  urine  must  be  watched  for.  In  the  latter  case,  entero- 
clvsis,  with  hot  normal  salt  solution  at  115°  to  120°  F.  Stenosis 
of  the  esophagus  may  be  dilated  if  possible,  if  stenosis  of  the  pylorus, 
appropriate  treatment  as  for  gastric  dilatation,  and  in  most  cases 
subsequent  operation.  If  atrophy  of  the  gastric  mucosa  result, 
the  treatment  is  for  achylia  gastrica.  For  perforative  peritonitis, 
operation  is  indicated. 

PHLEGMONOUS  GASTRITIS 

(Synonrm^.— Suppurative  Inflammation  of  the  Stomach;  Gastritis  Phlegmonosa; 
Abscess  of  the  Stomach.) 

This  is  a  rare  disease  and  usually  runs  an  acute  course,  though 
occasionally  subacute.  The  process  begins  in  the  submucosa  and 
sometimes  extends  to  the  muscular  coat,  and  at  times  to  the  mucous 
or  serous  coats.  It  is  more  frequent  in  men.  It  is  primary  or  idio- 
pathic, due  to  some  micro-organism,  especially  the  streptococcus, 
probably  entering  through  some  solution  of  continuity  in  the  mucous 
membrane;  or  secondary  (metastatic),  due  to  pyemia,  puerperal 
infection,  or  the  exanthemata. 

Errors  in  diet,  alcohoHc  excess,  trauma,  etc.,  have  been  given  as 
causes,  but  probably  only  are  contributory  by  depressing  the  system. 
Traumatism  might  cause  dam.age  to  the  mucosa  and  render  infection 
more  easy. 

There  are  two  forms  met  with:  a  diffuse  purulent  infiltration 
and  a  circumscribed  abscess. 

Morbid  Anatomy. — In  the  diffuse  type  a  large  area  of  the 
submucosa  is  frequently  involved.  It  is  thickened,  infiltrated  with 
pus,  and  multiple  small  abscesses  are  often  present.  The  pyloric 
end  is  more  frequenth^  attacked.  The  muscular  wall  is  often  involved 
or  the  pus  may  burrow  through  to  the  peritoneum.  The  mucosa 
is  usually  also  affected  and  is  swollen,  and  there  is  granular  degenera- 
tion of  the  gland  cells.     Perforation  of  the  mucosa  may  occur. 

In  the  abscess  type  there  is  generally  a  single  circumscribed 
abscess  of  variable  size,  starting  in  the  submucosa  and  involving  the 
muscular  layer.  The  mucosa  and  serosa  are  often  involved.  It 
may  terminate  favorably  by  perforating  into  the  stomach  (a  rare 
event)  or  perforate  into  the  peritoneal  cavity. 

Symptoms. — The  patient  may  have  for  a  brief  period  a  few 
dyspeptic  symptoms,  such  as  loss  of  appetite,  thirst,  and  some 
burning  in  the  stomach,  but  these  are  usually  absent. 


CATARRH    OF   THE    STOMACH  189 

The  attack  is  generally  of  an  acute  fulminating  type :  Severe  pain 
or  burning  in  the  gastric  region,  a  rapid  rise  of  temperature  to  103° 
to  105°  F.,  with  slight  intermissions;  frequently  chills;  often  vomiting 
of  mucus,  bile,  and  food  remnants,  but  no  pus,  unless  the  abscess 
breaks  into  the  stomach,  which  is  a  rare  event.  The  area  over  the 
stomach  is  very  sensitive  to  pressure  and  there  is  some  tympanites. 
There  is  constipation  or,  more  usually,  diarrhea.  The  pulse  is  rapid 
and  feeble,  occasionally  there  is  jaundice. 

The  patient  presents  all  the  aspects  of  a  severe  infection,  with 
delirium  and  coma  preceding  death.  The  blood  examination  shows 
leukocytosis  with  increase  in  the  polynuclears.  There  is  muscular 
rigidity  in  the  upper  quadrant  of  the  abdomen,  of  the  recti  muscles, 
due  to  peritoneal  irritation  even  before  perforation  occurs.  This  is  a 
valuable  sign.  With  general  peritonitis  we  have  the  usual  symptoms 
— pain,  distention,  general  tenderness  on  pressure,  etc. 

With  a  circumscribed  abscess  the  tenderness  is  more  localized, 
the  symptoms  not  so  severe,  and  the  duration  longer.  Percussion 
and  palpation  may  locate  the  process  if  localized. 

Duration. — Three  or  four  days,  rarely  one  to  two  weeks. 

Diagnosis. — The  temperature,  chills,  fulminating  character, 
leukoc3^tosis,  and  early  recognition  of  muscular  rigidity — all  point 
to  an  acute  suppurative  process.  Abscess  of  the  liver  and  subphrenic 
abscess  are  not  of  such  acute  type.  Acute  cholecystitis  and  acute 
pancreatitis  are  more  apt  to  be  confounded  with  abscess  of  the 
stomach. 

With  acute  pancreatitis  the  temperature  at  first  may  be  low, 
tympanites  is  earlier  and  more  marked,  and  there  are  circumscribed 
tenderness  in  the  course  of  the  pancreas  and  tender  spots  throughout 
the  abdomen  (Fitz).  Constipation  is  usual;  also  the  symptoms 
may  resemble  intestinal  obstruction.  Abscess  of  the  pancreas  is 
slower  in  its  course  and  there  is  a  longer  history. 

Acute  cholecystitis  is  a  much  more  frequent  condition  than 
phlegmonous  gastritis.  The  gall-bladder  can  at  times  be  palpated, 
is  tender,  and  we  have  the  previous  history. 

Treatment.— Laparotomy  is  advised,  both  to  settle  the  diagnosis 
and  afford  relief  if  possible.  Should  this  not  be  consented  to,  then 
the  ice-bag,  rectal  feeding,  enteroclysis,  to  relieve  tympanites,  and 
opiates  are  indicated. 

CHRONIC  GASTRITIS 

{Synonyms. — Chronic  Gastric  Catarrh;   Chronic  Dyspepsia.) 

Definition. — A  chronic  inflammation  of  the  mucous  membrane 
of  the  stomach,  with  the  production  of  mucus  and  changes  in  the 
gastric  juice,  causing  disturbances  in  the  act  of  digestion. 

Etiology. — This  disease  is  more  frequent  in  men  than  in  women. 
It  may  follow  the  acute  type,  especially  after  recurrences  of  this 
condition.     The   same  irritating  agents  that  cause  acute  gastritis 


I90  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

can  produce  the  chronic  type  when  acting  for  a  long  period  of  time; 
notably,  fast  eating  with  imperfect  mastication,  overloading  the 
stomach,  indigestible  food,  highly  spiced  dishes,  cold  drinks  in  excess, 
over  rich  food,  excessive  use  of  tea  or  coffee,  and  overindulgence  in 
alcohol  (the  so-called  "drunkards'  catarrh");  excessive  use  of 
tobacco,  especially  in  tobacco-chewers  and  those  who  indulge  in 
dry  smoking  (chewing  the  cigar-butt),  an  unhealthy  condition  of 
the  mouth  or  teeth,  and  swallowing  the  products  of  decomposition. 
Habitual  use  of  drugs  may  be  a  cause. 

Discharges  from  the  nose  or  ear  through  the  Eustachian  tube, 
which  are  then  swallowed,  have  been  factors  in  several  cases  that 
I  have  observed.  Thrush  may  cause  mould  in  the  stomach.  Chronic 
gastritis  may  be  secondary  to  the  acute  infectious  diseases,  such  as 
typhoid  fever.  It  is  frequently  associated  with  cancer  of  the  stomach 
and  is  often  present  in  the  atonic  type  of  dilatation  of  the  stomach. 

It  may  be  secondary  to  cirrhosis  of  the  liver,  pulmonary  or 
cardiac  disease,  and  chronic  nephritis.  Among  constitutional 
causes  are  gout,  diabetes,  leukemia,  and  severe  anemia. 

Classification. — Chronic  catarrhal  gastritis  m.ay  be  classified 
as  follows : 

1.  Acid  gastritis  (gastritis  hyperpeptica,  hypersthenic  gastritis), 
or  acid  catarrh  of  the  stomach,  first  described  b}^  Boas. 

This  is  considered  on  the  borderline  and  to  be  the  initial  stage  of 
chronic  gastritis.  There  is  a  slight  increase  in  the  hydrochloric  acid 
and  Boas  believes  this  occasionally  occurs  in  the  early  stages  of 
chronic  gastritis.     There  is  also  the  presence  of  mucus. 

2.  Chronic  catarrhal  gastritis,  under  which  is  described  mucous 
gastritis  (Ewald),  which  is  merely  a  severe  type  with  great  secretion 
of  mucus. 

We  must  remember  that  occasionally  from  a  long-continued 
chronic  gastritis,  other  conditions  may  arise. 

(a)  There  may  be  a  great  thickening  of  the  mucosa  (hyperplasia), 
so  as  to  produce  thick  folds,  the  so-called  etat  mamelonne,  and  this 
combined  with  swelling  of  the  mucosa  cause  benign  stenosis  of  the 
pylorus;  or  sometimes  wart-like  excresceiices  (gastritis  poHposa) 
develop,  which  if  situated  at  the  pylorus  can  produce  partial  obstruc- 
tion— a  benign  stenosis,  with  dilatation  of  the  stomach;  or  a  prolifera- 
tion of  interstitial  tissue  occurs  and  muscular  hypertrophy  with 
resulting  hypertrophic  stenosis  of  the  pylorus. 

Chronic  gastritis  may,  therefore,  produce  and  have  associated 
with  it  benign  stenosis  and  dilatation  of  the  stomach. 

(b)  On  the  other  hand,  a  degeneration  or  atrophy  of  the  muscular 
fibers  due  to  hyperplasia  of  the  connective  tissues  may  cause  atony, 
and  atonic  dilatation  of  the  stomach  may  result,  and  these'conditions 
will  improve  with  the  improvement  of  the  gastritis. 

They  only  occur  in  the  more  advanced  cases.  In  the  patients 
whom  we  are  called  upon  to  treat,  the  stomach  is  iisually  of  normal 


CATARRH  OF  THE   STOMACH  I9I 

size,  non-atonic,  and  with  normal  or  slightly  diminished  motor 
functions. 

3.  Atrophic  gastritis  (Anadenia  ventriculi,  Ewald),  an  atrophy 
of  the  mucous  lining  of  the  stomach,  can  result  from  chronic  gastritis. 
Of  these,  there  are  two  forms: 

(a)  Phthisis  ventriculi,  a  thinning  of  the  coats  of  the  organ,  which 
may  remain  of  normal  size  or  be  increased  in  size. 

(6)  Cirrhosis,  or  sclerosis  ventriculi,  an  enormous  thickening  of 
the  muscular  coat  and  a  great  reduction  in  the  volume  of  the  stomach. 

Atrophic  gastritis  is  described  under  Achylia  gastrica. 

Morbid  Anatomy  of  Chronic  Catarrhal  Gastritis. — The  mucous 
membrane  is  yellowish-gray  or  slate-gray  in  color,  and  in  secondary 
catarrhal  conditions  produced  by  congestion  may,  in  some  parts, 
be  intensely  red.  It  is  swollen  and  thickened  and  covered  with  a 
closely  adherent  tenacious  mucus,  which  is  usually  cloudy  and  gray 
in  color,  due  to  various  cells,  epithelia,  and  leukoc}'tes,  and  occa- 
sionally is  tinged  with  blood.  Enlarged  veins,  patches  of  ecchymosis, 
and  small  hemorrhagic  erosions  may  be  present.  The  mucosa  in 
some  instances  forms  papillary  projections  (etat  mamelonne). 

The  pyloric  portion  is  usually  involved,  though  the  inflammation 
may  extend  over  the  entire  mucosa.  The  submucosa  and  muscular 
coats  are  at  times  hypertrophied  or  atrophied. 

Microscopically  the  following  conditions  appear:  The  glands  are 
enlarged,  sacculated,  and  dilated  in  cyst-like  forms,  the  tubuli  in 
many  places  being  atypic  and  branching  like  the  fingers  of  a  glove; 
the  gland-cells  are  cloudy,  granular,  and  in  a  condition  of  fatty 
degeneration,  and  the  principal  and  parietal  cells  cannot  be  differen- 
tiated. Abundant  small  cell  infiltration  presses  the  glands  apart, 
being  especially  marked  toward  the  surface  of  the  mucosa.  Exten- 
sions of  connective  tissue  may  be  seen  passing  from  the  mucosa 
between  the  glands.  The  mouths  of  the  glands  are  at  times  filled 
with  mucus  which  projects  against  the  lumen.  Mucoid  transforma- 
tion of  the  cells  of  the  tubuli  is  a  striking  feature  and  may  extend 
to  the  fundus  of  the  glands  and  cells.  Mucoid  degeneration  may 
replace  the  principal  and  parietal  cells. 

The  mucus  fills  part  of  these  cells,  or  may  crowd  the  protoplasm 
and  nucleus  against  the  base,  or  rupture  the  cell-membrane  and 
escape  into  the  duct  of  the  gland.  The  pyloric  region  is  usually  thus 
affected.     Ewald  has  described  this  condition. 

After  a  long  period  the  inflammatory  process  ma}-  lead  to  a  total 
destruction  of  the  glandular  layer,  or  atrophy  of  the  mucous  mem- 
brane of  the  stomach — anadenia  ventriculi  (Ewald).  Of  this  there 
are  two  forms,  as  heretofore  noted: 

(a)  Phthisis  ventriculi,  atrophy  of  the  stomach,  or  anadenia  ven- 
triculi (Ewald),  is  a  thinning  of  the  coat  of  the  stomach,  with  a 
retention  of  or  usually  an  increase  in  the  size  of  the  organ  (dilatation). 
There  are  fatty  degeneration  and   destruction  of  the   glands,   the 


192  DISEASES   OF  THE   STOMACH   AND   INTESTINES 

process  progressing  from  the  surface  of  the  stomach  inwardly.  In 
the  early  stage  no  glands  are  found,  but  glandular  cysts  are  present 
near  the  submucosa.  Later  these  disappear  and  the  mucous  mem- 
brane consists  chiefly  of  round  cells.  The  submucosa  is  changed 
and  the  muscular  layer  is  thinner. 

(b)  In  cirrhosis,  or  sclerosis  ventriculi,  the  stomach  coats  are 
thickened  and  there  is  a  great  reduction  in  the  volume  of  the  organ ; 
in  some  cases  it  is  no  larger  than  a  pear  and  the  walls  may  be  2  to 
3  cm.  in  thickness,  the  greatest  increase  being  in  the  submucosa, 
where  the  process  starts.  The  inflammatory  process  causes  the  for- 
mation of  fibrous  tissue,  which  progresses  from  the  submucosa  to 
the  surface,  spreading  around  the  glands,  constricting  them,  and 
finally  replaces  them  with  fibrous  tissue.  The  hypertrophy  extends 
to  the  muscular  layer. 

This  condition  may  coexist  in  the  cecum  and  colon  and  so  be 
difficult  to  distinguish  from  diffuse  carcinoma.  Proliferative  peri- 
tonitis with  perihepatitis  and  ascites  are  at  times  associated. 

Atrophy  of  the  gastric  mucosa  is  described  under  Achylia  gastrica. 

Symptoms  of  Chronic  Gastritis. — These  develop  slowly;  the 
appetite  diminishes  or  is  irregular  or  easity  satiated.  There  is  a 
feeling  of  fulness  or  pressure  in  the  gastric  region  after  eating.  Occa- 
sionally heartburn  or  cardialgia  in  the  epigastrium  or  precordial 
region  or  behind  the  sternum  occurs,  generally  at  the  height  of  digestion; 
while  with  hyperchlorhydria  it  is  present  on  an  empty  stomach. 
Discomfort  or  pain  on  pressure  over  the  stomach  is  present.  Belching 
of  gas  is  the  most  frequent  symptom  and  it  is  usually  odorless;  water- 
brash  (pyrosis) ,  a  bitter  or  a  tasteless  fluid,  may  be  brought  up  into 
the  mouth  (regurgitation) ;  the  stomach  and  intestines  are  often 
markedly  distended  with  gas.  Nausea  is  frequently  present  and 
occasionally  vomiting. 

When  the  latter  occurs  it  is  frequent  in  the  morning,  when  the 
stomach  is  empty,  and  consists  chiefly  of  slimy  mucus,  and  sometimes 
of  partly  digested  food  of  the  previous  day  with  mucus.  It  may 
take  place  after  breakfast.  There  is  a  sour,  bad,  or  salty  taste  in 
the  mouth.  The  patient  in  some  cases  complains  of  palpitation  and 
shortness  of  breath  (dyspeptic  asthma  or,  more  correctly,  dyspnea). 
The  pulse  is  small  and  sometimes  slow.  There  are  fulness  in  the  head, 
insomnia,  lack  of  energy,  and  distaste  for  work.  Dizziness  may  be 
present.  Sensation  of  fear,  depression,  melancholia,  or  hypochon- 
driasis occur  in  some  patients.  The  tongue  is  usually  covered 
with  a  thick  gray  moist  fur,  though  not  always  so,  and  it  cannot  be 
said  to  be  characteristic.  The  margins  are  at  times  indented.  Odor 
of  the  breath  is  present  when  there  is  disease  of  the  mouth  or  teeth, 
or  atony  of  the  stomach  with  fermentation.  Headache  is  quite  com- 
mon and  a  desire  to  yawn.  There  is  at  times  the  so-called  stomach 
cough,  doubtless  due  to  pharyngeal  irritation. 

The  patient's  appearance  may  be  quite  good  and  he  may  preserve 


CATARRH  OF  THE  STOMACH  1 93 

his  weight.  In  severe  cases  he  looks  quite  badly,  and  shows  black 
rings  under  his  eyes,  has  cold  hands  and  feet,  and  chills  easily.  Some 
even  lose  considerable  weight  and  become  thin  and  emaciated.  In 
the  severe  types  with  nervous  symptoms,  intestinal  fermentation  or 
putrefaction  are  often  present  and  auto-intoxication  is  undoubtedly 
a  factor.  The  bowels  are,  as  a  rule,  constipated;  though  occasionally 
diarrhea  or  diarrhea  alternating  with  constipation  are  present. 

Physical  Examination. — Inspection. — The  gastric  region  appears 
bloated. 

Percussion. — Tympanites  is  present,  but  the  stomach  is  usually 
in  the  normal  position. 

Palpation. — The  gastric  region  is  sensitive  to  pressure ;  tenderness 
is  rather  diffuse.     No  real  pain  or  sense  of  resistance. 

Splashing  sound  can  be  produced  if  liquid  and  gas  are  present. 
It  is  only  abnormal  if  found  at  a  time  whe7i  the  stomach  should  be 
empty.  It  would  then  show  atony.  If  found  in  an  abnormal  position 
(low),  it  is  an  evidence  of  dilatation  or  ptosis.  With  movable  kid- 
ney ptosis  can  be  diagnosed. 

Urine  is  scanty;  contains  phosphatic  and  urate  deposits.  Spe- 
cific gravity  is  increased. 

Diagnosis. — The  presence  of  gastric  mucus  in  the  stomach  con- 
tents is  the  chief  diagnostic  point  in  chronic  gastritis,  so  that  examina- 
tion of  the  vomitus  or,  preferably,  of  the  gastric  contents  after  a  test 
breakfast  is  imperative.  The  diagnosis  should  not  be  made  from 
clinical  symptoms  alone. 

Gastric  Contents. — One  hour  after  Ewald's  test  breakfast  or  the 
one  I  employ — 2  slices  (60  gm.)  of  bread  without  butter  and  250  to 
300  cc.  of  water — the  latter  being  slightly  less  than  Ewald's,  the  con- 
tents of  the  stomach  are  withdrawn.  The  following  are  the  condi- 
tions found  present: 

Total  acidity  is  diminished;  free  hydrochloric  acid  is  markedly 
lessened  or  is  small  in  amount  or  absent ;  pepsin  and  rennet  are  present 
but  diminished;  erythrodextrin  present  in  small  quantities;  achro- 
odextrin  and  sugar  abundant ;  quantity  of  gastric  contents  frequently 
normal  (under  100  cc.)  or  may  be  sHghtly  more  (100  to  150  cc), 
which  last  would  show  some  motor  insufficiency. 

The  pieces  of  roll  are  not  as  fine  as  normally,  but  larger  and 
coarser.  Mucus  is  usually  intimately  mixed  with  the  food  remnants 
and  is  adherent  to  the  morsels  of  food.  The  stomach  contents  are 
thick,  tough,  and  sticky,  and  difficult  to  filter,  A  glass  rod  dipped 
into  them  and  lifted  up  will  draw  up  strings  of  mucus  with  it.  Acetic 
acid  added  to  the  filtrate  produces  turbidity. 

Mucus  that  has  been  swallowed  is  never  mixed  with  the  food  remnants, 
but  floats  as  isolated  balls  on  the  surface. 

Mucus  in  some  cases  is  in  large  amount,  while  there  may  be  very 
little  in  others.     In  the  latter  event,  lavage  of  the  empty  stomach 
will  determine  its  presence,  in  shreds  or  flakes. 
13 


194  DISEASES   OF  THE   STOMACH  AND  INTESTINES 

In  the  fasting  condition  there  are  often  only  a  few  cubic  centi- 
meters of  turbid  Hquid  in  the  stomach,  consisting  chiefly  of  mucus 
of  an  alkaline,  neutral,  or  slightly  acid  reaction.  If  no  contents  can 
be  thus  secured,  lavage  again  will  show  the  mucus. 

The  vomitus  shows  the  same  characteristics  already  described, 
but  the  examination  by  the  test  breakfast  is  more  accurate. 

Microscopically. — Mucus,  round  cells,  and  epithelial  cells  are 
found  to  be  present.  In  doubtful  cases  the  microscope  may  differen- 
tiate the  types  of  mucus.^  If  squamous  epithelia  be  mixed  with  it, 
it  probably  comes  from  the  mouth  or  pharynx ;  if  pigmented  alveolar 
epithelia,  probably  from  the  air-passages. 

In  acid  gastritis,  we  find  the  total  acidity  and  free  hydrochloric 
acid  slightly  increased,  and  the  presence  of  mucus.  I  had  recently 
a  case  in  which  the  total  acidity  averaged  90  +  and  free  hydrochloric 
acid  70  +  ,  with  a  large  amount  of  mucus. 

The  so-called  cases  of  mucous  gastritis  merely  contain  an  excessive 
amount  of  mucus,  with  little  or  no  hydrochloric  acid. 

In  atrophic  gastritis  there  is  absence  of  hydrochloric  acid,  absence 
of  pepsin  and  absence  of  rennet,  as  described  under  Achylia  gastrica. 

If  dilatation  be  present,  we  have  the  physical  signs  and  gastric 
findings  of  such. 

Kinhorn  finds  small  shreds  of  the  mucosa  present  in  the  wash- 
water  of  some  cases  of  chronic  gastritis  due,  as  he  believes,  to  erosions. 

Motor  function  may  be  normal  or  slightly  diminished,  so  that  the 
ingesta  escape  before  fermentation  can  occur.  This  is  the  usual 
course  in  the  ordinary  type  of  case. 

In  some  cases  with  hypertrophy  the  motor  function  may  be 
increased.  If  atony  or  dilatation  is  present,  there  are  motor  insuffi- 
ciency and  fermentation. 

In  those  with  excessive  mucus  production,  the  action  of  the  saliva 
and  gastric  juice  is  interfered  with  and  though  the  motor  function  is 
good,  the  ingesta  passes  into  the  intestine  with  little  change,  and 
intestinal  fermentation  or  putrefaction  results. 

Absorption. — This  depends  on  the  severity  of  the  case;  in  milder 
cases,  with  the  iodid  of  potassium  test,  it  seems  normal;  in  severe 
cases  it  is  interfered  with. 

Course. — The  duration  of  chronic  gastritis  is  long,  often  extend- 
ing over  many  3^ears.  Marked  improvement  may  take  place,  but 
relapses  are  apt  to  occur  from  indiscretions.  Milder  cases  can  be 
permanently  cured. 

Differential  Diagnosis. — Chronic  Gastritis. — No  severe  pain;  no 
circumscribed  spot  painful  to  pressure ;  no  hematemesis ;  no  cachexia ; 
no  mxarked  emaciation,  except  in  severe  cases  of  long  duration; 
free  HCl  diminished  or  absent;  gastric  mucus  present;  slow  course. 

Ulcer  of  the- Stomach. — Hyperchlorhydria,  as  a  rule;  severe  pain 
in  the  epigastrium  with  intervals  free  from  pain  when  the  stomach 
1  Columnar  epithelia  mixed  with  mucus  show  it  is  gastric. 


CATARRH    OF   THE    STOMACH  1 95 

is  empty;  local  tenderness  which  is  circumscribed;  dorsal  pain, 
hematemesis,  or  occult  blood  in  the  stool  or  gastric  contents;  no 
mucus ;  patient  has  appearance  of  suffering ;  no  true  cachexia. 

Cancer. — Age  (usually  over  forty-five) ;  rapid  course;  free  HCl 
usually  markedly  diminished  or  absent;  lactic  acid  present;  mucus 
sometimes  present;  pain  generally  continuous,  but  not  as  acute  as  in 
ulcer;  Boas-Oppler  bacillus;  cachexia;  tumor  on  physical  exami- 
nation; small  amount  of  blood  present  in  gastric  contents;  blood  or 
occult  blood  in  the  stool;  hematemesis  much  less  than  ulcer;  foul 
odor  to  vomitus  at  times  present. 

Achylia  Gastrica. — Slow  course;  scarcely  any  gastric  juice;  acidity 
very  low  (2  +  to  4  + ) ;  absence  of  HCl ;  absence  of  pepsin ;  absence  of 
rennet;  usually  no  mucus;  no  lactic  acid.  In  the  early  stage  (transi- 
tional) Riegel  holds  that  mucus  may  at  times  be  present. 

Gastric  Neuroses. — Symptoms  not  uniform;  character  of  food 
makes  little  difference;  indigestible  food  may  be  well  borne  and 
digestible  food  may  cause  symptoms ;  no  gastric  mucus;  HCl  may  be 
diminished  or  in  some  cases  normal  or  increased,  and  the  gastric 
findings  often  vary  at  different  times  in  the  same  patient.  Sub- 
jective symptoms  are  sometimes  similar  to  chronic  gastritis,  but  they 
disappear  and  reappear  abruptly. 

Prognosis. — Some  cases  can  be  cured ;  many  improved.  Relapses 
may  occur.     The  affection  is  frequently  a  tedious  one. 

Treatment. — This  may  be  divided  into:  (i)  Prophylaxis. 
(2)  Hygiene.  (3)  Local  treatment  of  the  stomach.  (4)  Diet. 
(5)  Mineral  springs.     (6)  Medication. 

Acid  Gastritis. — The  borderline  cases,  acid  gastritis,  should  receive 
the  treatment  of  hyperchlorhydria ;  also  occasional  lavage  to  remove 
mucus,  say,  twice  a  week,  is  advisable.  In  a  recent  case  I  have 
employed  it  daily,  using  several  ounces  of  milk  of  magnesia  (PhilHps) 
to  the  quart  of  water. 

Extract  of  belladonna,  gr.  -}  (0.022),  t.  i.  d.  before  meals  and  mag- 
nesia usta  and  soda  bicarb.,  aa,  gr.  10  (0.6),  combined  with  resorcin 
resub.,  gr.  5  (0.3),  in  water,  an  hour  after  meals,  as  suggested  by 
Theodorus  Bailey,  is  excellent  treatment.  Milk  of  magnesia,  5j  to  ij 
(4.0-8.0),  is  also  of  value. 

Van  Valzah  and  Hayes  report  cases. 

I.  Prophylaxis. — Unquestionably,  repeated  attacks  of  mild  so- 
called  acute  dyspepsia  (acute  gastritis)  may  ultimately  lead  to  the 
development  of  chronic  gastritis.  The  causes  of  both  conditions  are 
practically  the  same.  The  patient,  therefore,  should  masticate  thor- 
oughly, avoid  bolting  the  food,  overindulgence  in  alcohol,  tobacco,  very 
hot  or  very  cold  food  and  drink,  indigestible  food,  etc.  He  should 
rest  for  fifteen  to  thirty  minutes  after  meals  before  returning  to  busi- 
ness. The  mouth  and  teeth  should  be  kept  in  good  condition ;  and 
if  there  are  aural  or  nasal  discharges  escaping  into  the  mouth,  or 
tonsillar  or  pharyngeal  inflamrnation,  treatment  should  be  instituted. 


196  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Cardiac  disease  should  be  treated  with  cardiac  stimulants,  espec- 
ially if  there  is  failing  compensation;  and  diseases  of  the  liver  and 
kidney  should  receive  appropriate  diet  and  treatment,  so  as  to 
lessen  the  chances  of  secondary  gastritis. 

2.  Hygiene. — Slow  eating,  with  subsequent  rest;  exercise,  prefer- 
ably in  the  open  air,  driving,  golf,  rowing,  walking,  and  horseback — 
all  of  which  should  be  carried  out  in  a  leisurely  manner  and  not 
overdone,  so  as  to  exhaust  the  patient,  are  useful.  Moderate  gym- 
nastic exercises  five  or  ten  minutes  daily,  as  with  an  exerciser,  with 
open  windows,  are  of  value. 

Avoid  badly  ventilated  rooms  and  sleep  with  the  windows  open. 

Cold  salt-water  sponging  morning  and  night,  followed  by  friction 
with  a  rough  towel,  is  of  service. 

If  the  patient  is  excessively  nervous,  change  of  climate  may  be 
necessary. 

3.  Local  Treatment. — The  removal  of  the  mucus  is  of  importance. 
This  can  be  done  by  two  methods:  By  administering  alkaline 
remedies  that  will  dissolve  the  mucus  and  by  lavage. 

In  mild  cases  lavage  is  not  alwa3's  necessary  and  the  use  of 
alkalis,  as  advocated  by  Achilles  Rose,  is  of  service. 

They  should  be  administered  about  an  hour  before  breakfast  and, 
if  necessary,  also  before  luncheon  and  dinner.  For  example,  in  ovj 
to  viij  (200  to  2.50  cc.)  of  hot  water,  soda  bicarb.,  gr.  30  to  3j  (2.0- 
4.0),  or  lime-water,  16.0  (oss),  or  milk  of  magnesia  (Phillips),  4.0  to 
8.0  (3j-ij)._ 

Magnesia  usta,  2.0  to  4.0  (gr.  30-0 j),  is  also  of  use,  alone  or 
combined  wath  equal  quantities  of  soda  bicarbonate. 

Penzoldt  has  demonstrated  that  mucus  will  adhere  to  bismuth. 
Rose  takes  advantage  of  this  and  gives  a  tablet  consisting  of  0.6 
(gr.  10)  magnesia  usta  and  0.6  (gr.  10)  bismuth  subnitrate,  to  be 
chewed  with  a  full  glass  of  water  one  hour  before  meals ;  or  two  tab- 
lets, if  required. 

The  magnesia  usta,  milk  of  magnesia,  or  soda  bicarb,  are  espe- 
cially useful. 

Lavage. — When  the  mucus  secretion  is  more  marked,  lavage 
should  be  substituted;  or  if  a  mild  case  does  not  improve  by  the 
above  method.  This  should  be  employed  on  the  empty  stomach 
before  breakfast,  so  as  to  aid  subsequent  digestion.  An  alkali 
should  preferably  be  added  to  the  fluid  to  dissolve  the  mucus.  The 
stomach  should  be  washed  with  the  patient  both  sitting  and  lying 
down  and  turning  on  the  sides,  to  remove  all  mucus  possible,  and 
washed  miiil  the  outflow  is  clear. 

The  following  are  excellent:  Milk  of  magnesia  (Phillips),  30.0 
to  60.0  (oj-ij)  to  the  liter  (quart) ;  or  lime-water  the  same  quantity; 
or  soda  bicarb.,  4.0  to  8.0  (oj-ij);  or  magnesia  usta,  4.0  to  8.0 
(5j-ij) — all  to  the  liter  (quart). 


CATARRH  OF  THE  STOMACH  1 97 

Normal  saline  solution — oj  (4-0)  salt  to  water  Oj  (500  cc.) — or 
boric  acid,  4.0  (oj)  to  the  liter  (quart),  may  be  employed. 

I  use  normal  saline  solution  combined  preferably  with  milk  of 
magnesia  or  magnesia  usta. 

Fleiner  mixes  2  parts  sodium  chlorid  and  i  part  soda  bicarb, 
and  employs  4.0  (oj)  to  2  to  3  liters  of  water. 

Frequency  of  Lavage. — Once  a  day  before  breakfast  is  often 
sufficient ;  in  some  cases  it  may  be  necessary  to  repeat  before  supper. 

If  dilatation  with  fermentation,  resorcin  (resub.),  0.3  to  i.o  (gr. 
5-15),  or  the  same  quantity  of  salicylic  acid  or  sodium  salicylate;  or 
gomenol,  i.o  to  2.0  (15  drops-oss) ;  or  potass,  permang.,  o.i  to  0.3 
(gr.  1 2—5);  or  listerin,  glycothymolin,  or  borolyptol,  4.0  (oj) — all 
to  the  liter  (quart),  can  be  employed. 

In  such  event,  I  wash  with  the  alkali  in  the  morning  to  remove 
mucus,  and  with  the  antifermentative  at  night. 

In  some  cases,  lavage  with  nitrate  of  silver  i :  5000  to  i :  2000  is 
of  value,  used  every  two  or  three  days,  preceded  by  warm  water 
lavage,  to  first  remove  nmcus.  No  saline  should  be  used  in  the 
silver  solution.  Saline  solution  may  subsequently  be  used  if  the 
silver  cause  pain  or  irritation. 

Pepper,  in  place  of  this,  advocates  an  aqueous  solution  of  silver 
nitrate,  dose,  gr.  •§■  to  |  (0.008-0.016),  internally  three  times  a  day 
for  a  short  period.     This  should  be  kept  in  a  dark  bottle. 

Electricity. — Unless  atony  with  lessened  motor  function  of  the 
stomach,  or  severe  subjective  symptoms,  with  little  mucus  are  present, 
electricity  is  of  no  practical  value. 

When  there  is  little  mucus,  it  may  aid  to  stimulate  gastric  secre- 
tion. In  such  event  the  intragastric  method  is  preferable  to  the 
percutaneous.  Removal  of  the  mucus  is  of  the  first  importance. 
Electricity,  however,  is  of  service  applied  to  the  abdomen  to  increase 
intestinal  peristalsis. 

Massage. —  Vibratory  Massage. — The  same  holds  true  of  these 
methods.  They  are  also  of  value  over  the  intestines  to  promote 
peristalsis. 

Hydrotherapy. — In  sensitive  cases  hot  water  compresses  applied 
to  the  stomach  are  useful. 

4.  Diet. — This  is  an  important  feature,  and  its  character  depends 
on  the  severity  of  the  symptoms.  It  is  always  preferable  to  give 
four  or  five  light  meals  than  three  full  meals  a  day.  In  severe  cases 
give  food  in  liquid  and  semihquid  form  (mushes),  such  as  milk  or 
matzoon  with  Vichy,  kumyss,  bacillac,  lactone-buttermilk,  barley, 
oatmeal,  or  rice  soups  prepared  with  milk ;  or  chicken  soup  or  bouillon, 
with  raw  egg  beaten  up;  sanatogen  (plain  or  flavored),  somatose, 
plasmon,  or  tropon  can  be  added  to  the  soups. 

Later,  soft-boiled  eggs,  mashed  potatoes,  rice  gruel,  scraped  raw 
or  broiled  beef,  toast  baked  in  the  oven,  stale  bread  (white),  butter, 
cocoa,  and  weak  tea. 


198  DISEASES   OF  THE   STOMACH  AND   INTESTINES 

The  diet  should  be  mixed,  the  albumin  somewhat  reduced;  the 
carbohydrates  should  be  given  in  suitable  form,  avoiding  those  that 
contain  too  much  cellulose.  Fats,  such  as  butter  and  cream,  are 
especially  necessary  when  there  is  loss  of  nutrition.  In  the  latter 
case  I  feed  by  the  "scales,"  endeavoring  to  put  on  weight,  improve 
assimilation,  and  at  the  same  time  ameliorate  symptoms. 

The  mere  estimate  of  requisite  calories  and  feeding  by  this 
method  alone  is  of  no  value,  as  each  patient  is  a  rule  to  himself. 

For  example:     In  severe  cases,  at  first  liquids  and  mushes. 

8.00  A.  M.  Milk  with  oij  (about  125  cc.)  of  lime-water,  or  pep- 
tonized milk,  oviij  (about  250  cc),  with  sanatogen,  5j  (4.0). 

10.30  A.  M.  ]\Iatzoon  and  Vichy  equal  parts,  in  all  ovj  to  viij 
(200-250  cc). 

1.30  p.  M.  Oatmeal  soup  or  chicken  soup,  with  an  egg  beaten  in, 
Bviij  (250  cc). 

4.00  p.  M.     Same  as  at  10.30  a.  m. 

6.30  p.  M.     Same  as  at  8.00  a.  m. 

9.30  p.  M.     Milk  and  Vichy  equal  parts,  in  all  oviij  (250  cc). 

Additions  can  gradually  be  made  to  this  diet.  Alilk,  however, 
does  not  agree  with  some,  and  soups  and  broths  must  be  substituted. 

The  following  diet  is  useful  in  many  cases  for  a  w'eek  or  two, 
but  must  be  modified  to  suit  the  individual. 

Calories. 
8.00  A.M.  I  cup  cocoa  or  tea,  about  two-thirds  milk,  approximately 100 

1  lump  of  sugar 40 

2  soft-boiled  eggs 165 

2  ounces  zwieback,  or  toast,  or  stale  white  bread  (2  slices) 150 

^  ounce  butter 115 

10.30  A.M.  8  ounces  koumyss,  matzoon,  or  milk  (250  cc.) 168 

2  ounces  crackers  or  somatose  biscuit 150 

J  ounce  butter 115 

1. 00  P.M.  2  ounces  of  steak,  chicken,  or  chop 70 

3  ounces  of  mashed  potatoes  or  rice 130 

2  ounces  white  bread  (stale),  or  toast,  or  zwieback 150 

I  cup  tea,  about  two-thirds  mUk,  approximately 100 

^  ounce  butter 115 

4.00  A.M.  7  ounces  milk,  mixed  with  i  ounce  top-cream  (250  cc.) 210 

1  ounce  crackers 100 

^  ounce  butter 100 

6.30  P.M.  8  ounces  hominy,  rice,  or  cereal  boUed  in  milk  (250  cc.) 450 

2  scrambled  or  poached  eggs 165 

2  slices  bread  average  about  2  ounces 150 

i  ounce  butter 115 

2858 

The  above  is  for  about  three  weeks,  and  the  diet  of  each  patient 
should  later  correspond,  as  nearly  as  possible,  to  the  usual  mode  of 
living. 

There  are  things  which  it  is  necessary  to  forbid,  such  as  fried 
food;  meat  with  tough  fibers  or  that  is  too  old  or  too  fresh,  pork, 
sausages;  lobster,  salmon;  chicken  salad;  mayonnaise;  cucumbers, 
pickles,   corn,    radishes,    celery,    cabbage;   hot  breads,   brown   and 


CATARRH    OF   THE    STOMACH  199 

Graham  bread;  also  fresh  bread  and  all  alcohoUc  beverages,  which 
last  I  believe  do  special  harm  to  the  inflamed  mucous  membrane. 

Foods  which  disagree  should  be  interdicted.  Sugar  should  be 
taken  in  small  quantity  and  avoided  by  some.  Soda-water  and 
candy  are  forbidden ;  also  hot  and  cold  drinks  and  ice-cream.  Veal, 
as  a  rule,  in  this  country  is  interdicted,  as  it  is  often  tough. 

Salt  is  of  value,  as  it  aids  the  production  of  HCl. 

Beef,  mutton,  lamb,  chicken,  potatoes,  hominy,  rice,  oatmeal, 
spinach,  lettuce,  asparagus,  eggs,  etc.,  are  all  admissible.  Water 
should  be  taken  in  small  amounts  during  the  meal. 

S'mo/^'ing.^Excessive  smoking  should  be  stopped.  It  is  chiefly 
the  tobacco  juice  from  chewing  the  cigar,  carried  by  the  saliva,  that 
damages  the  mucous  membrane  of  the  stomach;  chewing  tobacco 
should  be  forbidden. 

If  a  cigar-holder  or  cigarrette-holder  be  employed,  I  can  see  no 
objection  to  two  cigars  or  four  cigarettes  a  day;  otherwise  it  should 
be  interdicted.  If  there  is  nasopharyngeal  catarrh,  smoking  should 
be  stopped. 

5.  Mineral  Waters. — These  dissolve  the  gastric  mucus,  hasten 
the  emptying  of  the  stomach,  and  often  stimulate  the  mucosa. 
On  account  of  the  rest  and  regular  life  and  diet  the  springs  are  often 
preferable,  though  the  waters  may  be  taken  at  home.  The  most 
useful  are  the  saline  and  the  saline-alkaline  waters. 

(a)  Saline  Springs. — ^These  contain  chiefly  sodium  chlorid  and 
varying  quantities  of  carbonic  acid  gas,  and  stimulate  the  secretion 
of  hydrochloric  acid.  The  most  notable  are  Kissengen,  Homburg, 
Wiesbaden,  Soden,  and  Saratoga  (Congress  Spring).  Dose,  glass 
of   mineral   water   on   arising. 

(6)  Alkaline-saline  Springs. — These  contain  sulphate  of  soda, 
sodium  bicarbonate,  sodium  chlorid,  and  carbonic  acid  gas. 

The  Carlsbad  Springs  are  the  most  famous.  Marienbad  and 
Saratoga  (Hawthorne  Spring)  belong  to  this  group,  also  Glauber's 
Salt  Springs  and  Glauber's  salts. 

One  can  employ  the  imported  Carlsbad  salts  or  Glauber's  salts; 
and  by  adding  sodium  bicarbonate  to  Glauber's  salts  imitate  imported 
wa'ters  more  closely- 

Wolff's  formula  for  artificial  Carlsbad  salts: 

I^.     Sulphate  of  soda 30.0 

Sulphate  of  potassium 5-° 

vSodium  chlorid 30.0 

Carbonate  of  soda 25.0 

Biborate  of  soda lo.o.— M. 

Sig. — OSS  to  j  (2.0-4.0)  in  warm  water  before  breakfast. 

These  springs  are  of  value  for  the  solution  of  large  quantities  of 
mucus  and  for  constipation.  Care  should  be  taken  not  to  purge  the 
patient  excessively,  and  nervous  cases  do  not  take  them  especially 
well. 


200  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

6.  Medication. — The  methods  described  will  often  be  sufficient, 
but  medication  is  of  service  as  an  accessory. 

Leube  was  the  first  to  recommend  the  use  of  dilute  hydrochloric 
acidV  to  supplement  this  deficiency  of  the  gastric  juice.  Ewald 
advised  the  use  of  large  amounts,  40  to  60  drops,  taken  in  divided 
doses  three  times  a  day  after  meals. 

For  example:  The  entire  dose  in  a  glass  of  water  and  com- 
mencing one-half  hour  after  meals,  a  third  of  this  being  taken  every 
fifteen  minutes. 

I  prefer  a  smaller  dose,  from  15  to  20  drops,  in  a  small  glass  of 
water  three  times  a  day  one-half  hour  after  meals,  and  taken  in  three 
divided  doses,  as  advised  by  Ewald.  This  is  impossible  to  pursue 
with  some  patients,  as  they  wiU  not  devote  the  time;  so  in  such  an 
event  a  single  dose  can  be  administered,  commencing  at  5  drops 
and  gradually  increasing  to  15  drops. 

The  following  is  an  excellent  prescription : 

I^.     Tinct.  nucis  vomica 12.0  (oiij) 

Acid,  hydrochlor^dilut.  | --      ^g^  (gg^^ 

Comp.  tmct.  cinchona. .  J 

Aq.  destil q.  s.  ad.     125.0  (oiv).— M. 

gig, — 4.0-8.0  (3j  to  ij)  t.  i.  d.  in  water  one-half  hour  after  food. 

Pepsin  is  present  in  considerable  quantity  in  chronic  gastritis,  so 
it  is  hardly  indicated;  though  some  add  0.5  to  i  (gr.  7J-15)  in 
combination.  Papayotin,  papain  or  papoid,  or  pancreatin,  i.o  to  1.5 
(gr.  15-22J),  with  sodium  bicarbonate,  have  been  suggested;  also 
the  diastase  combinations,  wines  of  pepsin,  etc. 

The  use  of  artificial  digestants  would  tend  to  weaken  the  gastric 
functions,  and  are  not  indicated. 

The  bitter  medicaments  as  stomachics,  to  stimulate  the  function 
and  appetite,  are  often  employed,  and  Riegel  beHeves  the  hydro- 
chloric acid  acts  in  this  way.  They  should  be  used  fifteen  minutes 
before  meals  in  i  to  2  ounces  of  water. 

Among  such  remedies  are  tincture  aurantii  amara ;  tinct.  amara 
(bitter  tincture,  Squibb ' s) ;  tinct.  calumba;  fluidextract  calumba; 
tinct.  cardamomi;  tinct.  hydrastis;  tinct.  gentian  comp.;  fluidext. 
hydrastis;  fluidext.  condurango;  fluidext.  quassia. 

The  average  dose  for  this  purpose  of  any  of  these  remedies  would 
be  from  15  to  20  drops;  quassia,  in  5  to  10  drops ;  and  tincture  nux 
vomica,  if  given  as  a  stomachic,  in  5  to  10  drops. 

They  may  be  given  alone  or  in  combination,  with  smaller  indi- 
vidual doses. 

The  alkaloidal  form  of  administering  stomachics  is  often  of  value. 
Thus: 

Condurangin  (Abbott's),  gr.  -g-V  (.001). 

Quassin  (Abbott's),  gr.  -gV  to  ^2  (•001-.005). 

1  Oxyntin,  a  derivative  of  HCl,  combined  with  nux  (tincture),  5  drops,  given 
in  capsules,  gr.  v  (0.3),  after  meals,  is  of  value. 


CATARRH  OF  THE  STOMACH  20I 

Condurangin  (Merck's),  gr.  jV  to  \  (.0065-016). 

Quassin  (Merck's),  gr.  3V  to  ^  (.002-.02). 

Hydrastin  (Merck's),  gr.  {  to  h  (.016-.032). 

Strychnin  arsen.,  gr.  j-J-q  (0.00065),  and  quassin,  gr.  ro  (0.0065), 
are  a  good  combination. 

Orexin,  gr.  J  to  i  (0.032-0.065),  can  be  given  in  bouillon  for  the 
same  purpose. 

In  the  gastritis  of  phthisis,  carbonate  of  creosote  or  guaiacol 
carbonate,  gr.  5  (0.3)  each  t.  i.  d.  after  meals,  are  of  value. 

For  Nausea  and  Vomiting. — Cerium  oxalate,  gr.  i  (0.065),  alone 
or  combined  with  soda  bicarb,  or  bismuth  subnitrate,  gr.  2  (0.13),  or 
any  of  the  methods  described  under  Acute  Gastritis.  Lavage  may 
be  necessary. 

For  Belching. — ]\Iilk  of  magnesia,  oss  to  j  (2.0-4.0),  or  magnesia 
usta,  gr.  X  (0.6). 

For  Gas  and  Intestinal  Fermentation. — Resorcin  resub.,  5iss  (6.0); 
Aq.  menth.  piperit.,  q.  s.  oiv  (125.0).  Dose,  5ij  (8.0)  t.  i.  d.  after 
food  in  water,  or  ichthoform  or  ichthalbin,  gr.  5  (0.32)  each,  etc. 

For  nervous  symptoins  associated  with  intestinal  putrefaction 

1  would  refer  to  the  chapter  on  the  latter  subject.     Iron  and  arsenic 
can  also  be  added  to  the  treatment. 

For  Constipation. — Patients  under  treatment  with  the  Carlsbad 
waters  require  no  treatment  for  constipation;  otherwise  attention 
must  be  paid  to  this  condition. 

The  patient  should  have  a  movement  every  day,  go  to  the  closet 
at  a  definite  hour,  and  endeavor  to  secure  bowel  action.  This  can 
be  assisted  by  a  2-ounce  injection  of  olive  oil,  or  by  a  glycerin  or 
gluten  suppository,  or  oij  to  oss  (8.0-16.0)  glycerin  in  oj  (30.0)  of 
water,  by  means  of  a  small  rectal  syringe. 

Green  vegetables,  such  as  spinach,  asparagus,  lettuce,  green 
peas,  etc.,  are  of  service. 

Stewed  fruits,  such  as  prunes,  apples,  or  pears,  are  often  effectual. 

Some  cases  do  well  with  food  containing  much  cellulose  and  with 
rye  bread,  but  many  cannot  take  them.  A  glass  of  cold  or  hot  water 
on  rising  is  of  value. 

If  mild  cathartics  are  necessary,  cascara  (fluidextract) ,  oss  to 
j  (2.0-4.0),  or  the  aromatic  fluidextract;  or  extract  cascara,  gr.  i  to 

2  (0.065-0.13),  or  compound  rhubarb  pills;  all  at  night. 

The  following  prescriptions  are  of  service. 

P^.     Aloin gr.  \-  (0.016) 

Podophyllin gr.  ^  (o.oii) 

s/ryZi/""*} M  gr.  rf.  (o.«»65, 

Cascara  ext gr.  J  (0.016). — M. 

In  one  pill. 


I^.     Ext.  aloes 

Ext.  nucis  vomicae  ]■ aa  gr.  J  (0.008). — M. 

Ext.  belladonnae 
In  one  pill. 


I 


202  DISEASES   OF  THE   STOMACH  AND  INTESTINES 

I^.     Podophyllin gr.  J  (o.oi i) 

Ext.  nucis  vomicae  1  -.         ,  /        ,.      ,, 

Ext.  physostig.       j ^^Sr.  i  (0.016)  .-M. 

In  one  pill. 

I^.     Aloin gr.  I  (0.016) 

Strychnin gr.  ^  (0.00108) 

Ext.    belladonna gr.  ^  (0.008). — M. 

In  one  pill. 

Other  remedies  are  described  under  Constipation. 

Olive-oil  injections  to  be  retained  at  night;  an  occasional  enema 
of  soapsuds,  not  over  i  quart  (Hter) ;  massage  or  vibratory  massage 
or  electricitv  to  the  intestines  are  useful. 


CHAPTER  XI 
ACHYLIA  GASTRICA 

(Synonyms. — Atrophy  of  the  Stomach;  Atrophy  of  the  Gastric  Mucosa;  Anadenia 
Ventriculi;  Phthisis  Ventriculi;  Atrophic  Gastritis;  Catarrhus  Atrophicans.) 

Definition. — Achylia  gastrica  (the  term  first  suggested  by 
Einhorn)  may  be  defined  as  a  functional  perversion  of  the  stomach, 
characterized  by  the  absence  of  the  gastric  secretion  (of  hydrochloric 
acid,  pepsin,  and  rennet). 

Introduction. — In  many  cases,  atrophy  of  the  mucosa  is  the 
cause,  and  the  condition  is  permanent.  Einhorn,  however,  has 
reported  a  case  in  which  there  was  eventually  some  return  of  secre- 
tion, so  that  portions  of  the  mucosa  could  not  have  been  much 
altered ;  and  a  case  of  achylia  in  a  vegetarian,  apparently  an  atrophy 
from  disuse.  Achylia  gastrica  may  result  from  organic  changes  in 
the  stomach,  or  may  be  a  pure  neurosis,  so  I  prefer  to  place  it  in  a 
special  chapter. 

The  loss  of  function  may  be  temporary  from  nervous  disturbances, 
and  A.  Rose^  and  the  author^  have  observed  achylia  occurring  in 
gastroptosis,  with  a  return  of  secretion  following  the  cure  of  ptosis. 
Temporary  achylia  is  present  occasionally  in  mucous  colic. 

History. — Atrophy  of  the  gastric  mucosa  was  first  described  in 
connection  with  pernicious  anemia  by  S.  Fenwick,^  and  later  by 
Lewy,*  Ewald,^  Osler,^  Kinnicutt,'  Nothnagel,  Boas,  and  others. 
It  was  believed  to  be  the  cause  of  pernicious  anemia  and  productive 
of  the  fatal  result.  Herter  has  demonstrated  the  influence  of  intes- 
tinal putrefaction,  chiefly  through  the  gas  bacillus  (Bacillus  aerogenes 
capsulatus),  in  the  production  of  pernicious  anemia,  and  favorable 
results  produced  by  intestinal  irrigation  and  lactic  acid  fermented 
milk  diet.  Stockton  has  called  to  our  attention  that  achylia  does 
not  occur  in  the  early  stages  of  pernicious  anemia,  but  only  when  it 
becomes  severe.  In  view  of  these  facts,  achylia  seems  to  be  a  sec- 
ondary and  not  a  primary  cause. 

Numerous   non-fatal  cases  of  achylia  have  been   reported  by 

1  Atonia  Gastrica,  Rose  and  Kemp. 

2  Observations  on  Dilatation  of  the  Stomach  and  Gastroptosis,  Medical  News, 
August  6,  1904.     Mucous  Colic,  American  Medicine,  March  4,  1905. 

3  Lancet,  July,  1877. 

<  Berlin,  klin.  Wochenschr.,  1887,  No.  4. 

5  Ibid.,  1886,  No.  32. 

6  American  Journal  of  the  Medical  Sciences,  vol.  xci,  1886,  p.  498. 

7  Ibid.,  1887,  p.  419. 

203 


204  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

Ewald/  Boas,  Einhorn,'  Jaworski,  Jones,  and  Martins,  and  the  latter 
has  written  a  work  on  the  subject. 

Etiology. — Severe  chronic  catarrhal  gastritis,  or  toxic  gastritis, 
may  produce  permanent  destruction  of  the  glands;  atrophy  from 
disuse,  as  in  vegetarians;  achylia,  associated  with  cirrhosis  of  the 
liver  (syphilis) ;  or  with  carcinoma  of  the  stomach,  or,  rarely,  with 
carcinoma  of  other  organs;  occasionally  with  diabetes  mellitus; 
achylia  with  pernicious  anemia.  Organic  changes  are  present  in 
these  cases.  Achylia  may  occur  as  a  temporary  functional  disturb- 
ance in  nervous  conditions,  neurasthenia,  gastroptosis,  and  mucous 
colic.  Achylia  may  also  be  secondary  to  a  general  infection,  such 
as  typhoid  fever,-^  etc. 

It  is  quite  common  in  the  middle  and  later  years  of  life,  but  has 
occurred  in  a  number  of  3"oung  persons,  especially  in  the  transitory 
type. 

Morbid  Anatomy. — When  the  achylia  is  of  nervous  origin,  or 
associated  with  gastroptosis  or  mucous  colic,  there  are  no  organic 
changes  in  the  mucosa,  and  the  condition  is  a  temporary  functional 
disturbance  of  secretion.  Rose  and  myself  believe  the  achylia  in 
mucous  colic  due  to  the  gastroptosis  and  not  to  the  nerv'ous  condition. 

Einhorn  has  shown  that  in  cases  where  a  portion  of  the  mucous 
membrane  has  been  aspirated,  showing  the  organic  changes  of  achyUa, 
there  has  been  some  return  of  secretory  function  under  treatment, 
so  that  this  is  no  evidence  of  permanent  destruction  of  secretory 
power  in  all  the  gastric  glands. 

Of  the  organic  changes,  there  are  the  two  types  described  under 
the  terminal  stage  of  chronic  gastritis: 

1.  Phthisis  ventriculi — round-celled  infiltration  and  fatty  degen- 
eration, with  thinning  of  the  stomach  wall ;  round  cells  taking  the  place 
of  the  glands ;  and  the  stomach  is  normal  in  size  or  may  be  dilated 
(Fig.  126). 

2.  Cirrhosis,  or  sclerosis  ventricuh,  a  fibrous  inflammation,  start- 
ing in  the  submucosa ;  fibrous  tissue  takes  the  place  of  the  glands, 
and  the  stomach  is  contracted  and  the  walls  thickened. 

Symptoms. — One  can  scarcely  say  that  there  are  symptoms 
characteristic  of  achylia  gastrica;  it  is  the  examination  of  the  gastric 
contents  which  will  alone  determine  the  true  diagnosis. 

In  describing  the  symptoms  it  seems  best  to  classify  achylia 
under  certain  groups,  some  of  which  we  may  dismiss  briefly. 

1.  Gastroptosis  (splanchnoptosis),  with  its .  symptoms ;  gastric 
disturbances;  achylia  present  in  some  cases. 

2.  Mucous  colic,  with  its  symptoms;  occasional  presence  of 
achylia. 

3.  Patients    with    no    symptoms    and    enjoying    good    health. 

1  Berliner  klin.  Wochenschr.,  1892,  Nos.  20  and  27. 

2  New  York  Med.  Presse,  Sept.,  1888. 

3  Stockton,  American  Journal  of  the  Medical  Sciences,  Aug.,  1909. 


ACHYLIA    GASTRICA 


205 


Einhorn  calls  attention  to  this  class,  one  of  which  had  the  habit  of 
rumination,  and  achylia  was  found  present,  of  forty  years'  duration. 
Patient  had  no  other  symptom.  Clinically  this  class  cannot  be 
considered. 

4.  Cases  with  gastric  symptoms  of  varying  severity,  associated 
with  intestinal  disturbances.     These  are  the  most  common  type. 

There  are  loss  of  appetite,  a  feeling  of  fulness  or  pressure  in  the 
epigastric  or  gastric  regions,  and  in  some  cases  severe  paroxysms  of 
pain,  usually  soon  after  eating  and  persisting  for  some  time;  vomiting 


Fig.  126. — Achylia  gastrica:   i,  mucosa;  2,  submucosa;  3  and  4,  muscularis;  5, 
serosa;  section  shows  round-celled  infiltration  of  mucosa  and  absence  of  glands. 


may  occur  soon  after  the  ingestion  of  food ;  belching  of  gas;  headache 
and  occasionally  vertigo;  usually  constipation. 

Some  cases  may  remain  fairly  well  nourished.  In  others  there 
may  be  considerable  loss  of  weight,  which  extends  over  a  period  of 
several  years,  and  nervous  symptoms  may  be  present. 

In  cases  in  which  nutrition  is  preserved,  the  intestines  perform 
the  digestive  functions  of  the  gastro-intestinal  tract. 

Einhorn  describes  cases  whose  symptoms  resemble  h^'perchlor- 
hydria,  with  pains  one  to  two  hours  after  eating,  which  are  relieved 


2o6  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

by  food  and  drink,  especially  the  latter,  which  prevents  irritation  of 
the  mucosa  by  the  coarse  particles.  This  has  been  given  as  an 
explanation  for  the  pain. 

5.  Cases  with  marked  intestinal  disturbances,  especially  diarrhea, 
or  occasionally  diarrhea  alternating  with  constipation;  quite  fre- 
quently there  may  be  no  gastric  symptoms  or  slight  belching  or 
feeling  of  pressure. 

Some  of  the  cases  lose  considerable  weight  and  strength  and 
feel  weak.  I  have  recently  treated  a  case  suffering  from  these 
symptoms  who  was,  in  addition,  markedly  ner^^ous.  At  the  end  of 
four  months'  treatment  gastric  secretion  returned  and  all  symptoms 
disappeared,  there  being  15  pounds  increase  in  weight — a  case  of 
nervous  achylia. 

Some  cases  of  this  type  may  present  symptoms  (subjective)  of 
diabetes,  according  to  Einhorn. 

6.  Cases  with  severe  anemia  (described  by  Riegel)  with  diarrhea. 
Examination  of  the  blood  shows  secondary  anemia,  and  of  the 
stomach,  achylia  gastrica.  Diarrhea  favors  the  production  of 
anemia  and  the  latter  improves  under  treatment.  These  cases  must 
not  be  confounded  with  pernicious  anemia.  The  blood  examination 
easily  differentiates. 

7.  Ach^^lia  developing  during  acute  febrile  conditions,  such  as 
influenza  (Ewald).  Riegel  believes  it  probably  pre-existed,  and 
that  the  intestines,  which  formerly  performed  the  digestive  functions, 
are  thus  disturbed  and  achylia  symptoms  first  appear  in  consequence. 

8.  Patients  suffering  from  ner^^ous  conditions,  or  neurasthenia, 
or  gastric  neuroses;  achylia  a  temporary  per^^ersion. 

]\Iy  case  under  the  diarrheal  class  belonged  to  this  type. 

9.  Pernicious  anemia  with  achylia,  in  which  the  blood  findings 
are  typic;  megaloc}i:es  and  nucleated  red  blood-corpuscles  (normo- 
blasts and  megaloblasts) ,  etc. 

Diagnosis. — ^The  diagnostic  feature  of  achyHa  is  the  gastric 
analysis  one  hour  after  Ev:ald's  test  breakfast.  The  characteristics 
are  as  follows : 

Total  acidity  is  2  -f  to  4  -|- ,  or  even  neutral ;  HCl  =  O ;  Pepsin  =  O ; 
rennet  =  0  (rennet  zymogen  .may  be  present);  propeptone  =  O ;  pep- 
tone  =  0;  lactic  acid  =  O ;  or  faint  trace ;  er}'thro6dextrin  =  0;  sugar 
=  +  ;  gastric  contents  have  no  odor,  no  eA'idence  of  fermentation; 
quantitv  of  liquid  is  very  small,  aside  from  that  soaked  into  the 
particles  of  bread  (this  is  quite  characteristic) ;  bread  particles  are 
not  minutely  minced,  but  rather  coarse;  absence  of  mucus. 

Schmidt  and  Riegel  believe  mucus  to  be  present  in  some  cases 
in  the  early  stage  of  achylia,  developed  from  chronic  gastritis,  while 
there  are  some  glands  remaining  in  mucoid  degeneration,  and  that 
the  presence  of  mucus  does  not  signify  that  the  case  is  not  one  of 
achylia.  Some  cases  of  old  chronic  gastritis  certainly  seem  on  the 
borderline. 


ACHYLIA    GASTRICA  207 

The  small  amount  of  fluid  in  achylia  is  explained  by  the  fact  that 
the  liquid  chyme  rapidly  leaves  the  stomach,  leaving  the  solid 
particles,  and  that  practically  no  secretion  takes  place  in  the  stomach. 

Motor  function  is  often  normal  or  even  increased.  It  is  diminished 
where  there  is  degeneration  and  dilatation  of  the  stomach. 

Absorption. — Though  this  has  apparently  seemed  normal  by 
the  iodid  of  potash  test,  in  some  cases  it  is  evident  that  this  test  is 
often  fallacious,  in  view  of  the  fact  of  the  general  loss  of  nutrition 
in  some  patients. 

I  agree  with  Riegel  that  from  the  pathologic  condition  present, 
absorption  must  be  diminished. 

Course  and  Prognosis. — In  nervous  achylia,  secretion  may  be 
resumed  in  a  few  months  under  proper  treatment,  and  in  gastroptosis 
and  mucous  colic  the  condition  is  dependent  on  the  treatment  of 
these  diseases. 

In  some  patients  the  condition  perhaps  exists  for  years,  with 
the  patient  in  good  health;  while  in  others  the  subjective  symptoms 
maybe  removed  or  cured,  while  the  objective  symptom  (the  analysis) 
persists.     Others  run  a  long  and  protracted  course. 

With  pernicious  anemia  and  carcinoma  the  prognosis  of  achylia 
depends  on  the  primary  disease. 

Diagnosis. — Repeated  analysis  of  the  gastric  contents  are 
necessary  to  arrive  at  the  diagnosis. 

Achylia  Gastrica.  Cancer  of  the  Stomach. 

Gastric  contents:  Gastric  contents: 

Little  fluid,   no  rnucus,   low  acid  Mucus,  acidity  higher,  lactic  acid, 

reaction  (2+   to  4  +  ),  no  HCl,  free  HCl  may  be  present,  though 

no  lactic  acid,  coarse  particles,  usually   absent,   contents  more 

no  blood.  fluid,  and    odor   and   food   less 

coarse,  blood. 
Stool: 

No  blood.  Blood,  or  occult  blood. 

Tongue: 

Often  clean.  Coated. 

Pain: 

At  times.  Constant. 

Motor  power: 

Normal  usually.  Diminished. 

Course: 

Slow.  Rapid. 

Loss  of  weight: 

Gradual.  Rapid. 

Cachexia: 

None,  or  slow  emaciation.  Rapid  and  peculiar  type. 

Tutnor: 

None.  Present  later. 

The  possibility  of  achylia  gastrica  being  the  cause  of  various  types 
of  gastro-intestinal  disturbances,  of  chiefly  intestinal  derangement  or 
irregularities,  or  of  severe  anemia  must  be  considered.  Its  associa- 
tion with  pernicious  anemia,  gastric  neuroses,  various  nervous  symp- 
toms, gastroptosis,  and  mucous  colic  must  be  remembered.  These 
facts  further  emphasize  the  importance  of  gastric  analysis. 


2o8  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

Treatment. — This  depends  on  the  cause.  Rose's  belt,  if  achyUa 
is  due  to  gastroptosis  or  mucous  coHc,  is  necessary.  If  associated 
with  nervous  affections,  these  conditions  should  receive  treatment. 
Such  patients  should  have  their  nutrition  improved,  and  placed  on 
the  diet  shortly  to  be  laid  down.  As  in  these  cases  achylia  is  a  func- 
tional disturbance,  the  secretion  should  be  stimulated  by — 

Strychnin,  gr.  gV  to  -gV  (0.00108-0.002 1),  t.  i.  d.  before  meals,  or 
condurango  (fluidextract) ,  lUxv  to  xx  (0.88-1. 18),  or  tinct.  nux 
vomica,  ttlv  to  x  (0.29-0.59),  with  the  addition  of  hydrochloric  acid, 
thus: 

I^.     Tinct.  nucis  vomicae       \  ..  ,r--.  /        ^ 

Acid,  hydrochlor.  dilut.  j ^^  ^"^  ^^^^^ 

Comp.  tinct.  cinchona 0  j  (30.0) 

Pure  pepsin 5  iss  (6.0) 

Aq.  destil q.  s.  ad.  oiv  (125.0). — M. 

Sig. —  3ij  in  water  t.  i.  d.  before  meals  (preferably). 

Pancreatin,  gr.  v  to  x  (0.3-0.6),  with  soda  bicarb.,  gr.  xv  (i.o), 
or  taka-diastase,  gr.  v  (0.33),  can  be  given  after  meals  in  cases  with 
diarrhea  to  aid  digestion  of  starchy  food.^ 

In  the  general  treatment  of  achylia  gastrica  endeavor:  (i)  To 
stimulate  gastric  secretion.  (2)  To  arrange  the  diet  so  that  the 
food  is  easily  digested. 

To  stimulate  gastric  secretion  employ  stomachics,  such  as  nux 
vomica,  condurango,  etc.,  fifteen  minutes  before  meals,  as  just 
described.  The  occasional  use  of  lavage  twice  a  week  is  of  service 
in  some  cases.  Litten  advises  the  use  of  a  2  per  cent,  dilute  hydro- 
chloric acid  solution  for  this  purpose. 

Intragastric  faradization  (preferably)  -  twice  a  week  or  percuta- 
neous faradization  may  be  valuable.  I  would  not  advise  this  in  the 
purely  nervous  cases. 

If  the  symptoms  simulate  hyperchlorhydria,  the  use  of  water, 
§viij  (250  cc),  or  crackers  and  milk  one  to  two  hours  after  meals,  as 
suggested  by  Einhorn,  lessens  the  irritation. 

Diet. — This  is  very  important.  Food  should  be  prepared  so  as 
to  pass  readily  from  the  stomach,  and  should  be  finely  divided  and 
thoroughly  masticated.  Meat  should  be  given  in  small  quantity, 
finely  chopped,  scraped  (rare  or  broiled),  chicken,  pigeon,  raw  scraped 
beef,  calves'  brain,  steak,  fish,  and  game. 

Starchy  foods  are  excellent  and  should  be  thoroughly  prepared; 
membranes  covering  any  such  should  be  removed.  Starch  is  rapidly 
converted  into  sugar. 

Mushes  and  liquids  are  preferable.  Pea  and  bean  soup  (strained), 
barley,  oatmeal,  rice,  sago,  and  potato  soups.  Mushes  from  rice. 
potato,  tapioca,  oats,  flour,  etc.;  puddings.  Soft-boiled  eggs;  yolks. 
of  eggs  in  soups;  raw  eggs  beaten  with  water  or  milk;  koumyss; 
matzoon;  bacillac;  bread;  crackers;  milk;  plenty  of  cream  and 
butter  are  indicated. 

1  Cellasin  tablets,  gr.  v  (0.3)  t.  i.  d.,  are  also  useful. 


ACHYLIA    GASTRICA  209 

Somatose,  sanatogen  (plain  or  flavored),  and  meat  powder;  Valen- 
tine's or  Liebig's  beef -juice;  Armour's  extract  of  beef. 

Cocoa  possesses  considerable  nutritive  power.  Tea  and  cofifee  well 
diluted  with  milk  can  be  given.  My  personal  view  is  that  alcoholic 
beverages  are  objectionable,  though  some  allow  them  in  moderation. 

The  second  indication  in  the  feeding  is  to  employ  it  at  frequent 
intervals,  about  every  three  hours,  in  small  quantities,  but  so  that 
the  sum  total  shall  be  considerable.  The  object  should  be  rather 
to  overfeed  and  to  increase  the  patient's  weight  by  selecting  those 
foods  which  best  agree  in  each  case. 

In  diarrheal  cases,  constipating  food,  such  as  potatoes  and  rice, 
should  be  selected.  Feed  by  the  "scales"  is  my  rule  in  cases  where 
loss  of  weight  has  occurred. 

For  the  preparation  of  meat  powder,  either  of  the  following 
methods  is  excellent : 

(i)  Debove's  Method. — Roast  finely  chopped  lean  beef  on  a 
tinplate  until  desiccated,  then  powder  in  a  mortar. 

(2)  Einhorn's  Method. — Dry  finely  chopped  meat  three  to  six 
hours  on  a  stove ;  then  pound  in  a  mortar  and  grind  twice  in  a  coffee- 
mill. 

Butter,  milk,  cream,  eggs  (soft  boiled  or  raw),  potatoes,  rice,  peas,, 
and  beans  (strained  through  a  colander),  cocoa,  chocolate,  and  a 
small  amount  of  beef,  chicken,  or  game,  and  crackers  or  stale  bread 
always  seem  to  agree.  I  have  often  given  4  to  8  raw  eggs  a  day. 
For  example: 

Calories.  - 

8  A.M.  Oatmeal  with  cream,  150  gm 400 

Cocoa  with  milk,  200  gm 135 

Soft-boiled  eggs-(2) 160 

Toast  (2  slices) 1 60 

Butter,  20  gm 163 

II  A.M.  6  ounces  (200  cc.)  milk  with  raw  egg 240 

Crackers,  2  oz.  (60  gm.) 1 50 

Butter,  20  gm 163 

2  P.M.  Soup,  bean  or  pea,  100  gm.  (with  i  egg  and  10  gm.  of  cane- 
sugar)  122 

Rare  meat  scraped,  100  gm 215 

Mashed  potatoes,  50  gm 63 

Spinach,  50  gm 30 

Bread,  2  slices  (60  gm.) 1 35 

Butter,  20  gm 1 63 

Tea  and  milk  (2  lumps  of  sugar) 60 

5.30  to  6  P.M.  Soft-boiled  egg  (i) 80 

Rice,  50  gm. ;  milk,  200  gm 302 

Bread  ( i  slice) 67 

Butter,  20  gm 81 

Tea  and  milk 60 

9  to  9.30  P.M.  6  ounces  (200  cc.)  milk  or  koumyss 128 

Zwieback,  50  gm 1 29 

Butter,  20  gm 163 

Total  calories 3269 

It  may  be  necessary  to  modify  this  diet  and  give  less,  especially 
at  first. 

14 


2IO  DISEASES    OF   THE   STOMACH   AND   INTESTINES 

In  cases  of  severe  anemia,  rest  in  bed;  arsenic  in  large  doses, 
beginning  with  Fowler's  solution  Tllv  (0.296)  t.  i.  d.  and  increasing 
to  TTlx  to  XV  (0.59-0.88)  t.  i.  d. ;  or  by  hypodermic  in  sterile  water 
atoxyl,  gr.  ^  to  §  (0.022-0.044),  every  other  day,  and,  in  addition, 
peptomangan  (Gude),  iron  tropon,  or  other  good  iron  preparation. 

Intestinal  irrigation  is  of  value  in  these  cases  when  putrefactive 
processes  are  present  in  the  intestine,  for  example,  with  §j  to  ij 
(30.0-60.0)  peroxid  of  hydrogen  or  acetozone  gr.  xv  (i.o)  to  the 
liter  of  water.  Enteroclysis  is  especially  advocated  in  pernicious 
anemia  cases,  with  bacillac  as  diet. 

I  have  recently  found  urotropin,  gr.  v  to  x  (0.3-0.6),  combined 
with  equal  quantities  of  benzoate  of  soda,  is  of  great  service  as  a 
remedy  for  intestinal  putrefaction. 

Resorcin  and  the  other  remedies  suggested  for  this  purpose  under 
Chronic  Gastritis  and  in  the  paragraph  on  Indicanuria  are  of  value. 

The  bismuth  preparations,  notably  bismuth  subcarbonate  or  sub- 
nitrate,  gr.  X  to  XXX  (0.6-2.0)  t.  i.  d.,  can  be  given  if  diarrhea  is 
present,  and  in  this  type  boiled  milk,  potatoes  (mashed),  and  rice  are 
serviceable. 

If  there  is  dilatation  of  the  stomach,  lavage  and  the  treatment 
for  this  condition  must  be  carried  out  and  Rose's  belt  applied. 


CHAPTER   XII 

HEMATEMESIS-ULCER  OF  THE  STOMACH— EXULCER- 
ATIO  SIMPLEX— ACUTE  AND  CHRONIC  EROSIONS 

GASTRIC  HEMORRHAGE 

Vomiting  of  blood  cannot  be  considered  to  be  a  proof  of  gastric 
hemorrhage,  as  it  may  come  from  the  esophagus,  nose,  or  mouth,  or 
be  coughed  up  and  swallowed. 

On  the  other  hand,  gastric  hemorrhage  may  occur  and  the  blood 
only  appear  in  the  stools. 

The  causes  of  gastric  hemorrhage  may  be  classified  as  follows: 

1.  Trauma  over  the  stomach;  injuries  to  the  mucous  membrane 
from  foreign  bodies,  as  bones  or  needles;  damage  from  the  stomach- 
tube,  mineral  acids,  or  caustic  alkalis. 

2.  Thrombosis  or  emboHsm  of  the  vessels;  aneurism;  varicosities; 
atheroma  of  a  vessel,  or  fatty  degeneration. 

3.  Venous  stasis  due  to  cirrhosis  of  the  liver;  tumors  of  the  hver; 
pylephlebitis;  compression  of  the  vena  cava. 

In  case  of  cirrhosis  the  hemorrhage  is  from  the  mucous  membrane 
or  from  esophageal  varices. 

4.  Lesions  of  the  heart  or  lungs,  causing  stasis  in  the  vena  cava. 

5.  Constitutional  diseases,  as  leukemia;  pseudoleukemia;  per- 
nicious anemia;  hemophiha;  scur\^y;  purpura;  melena  (morbus 
maculosus  neonatorum). 

6.  Menstrual  type,  when  amenorrhea  is  present. 

7.  Lesions  of  the  central  nervous  system  (brain  or  spinal  cord). 

8.  Hysteria. 

9.  Ulcer  of  the  stomach  and  carcinoma. 

10.  Acute  infectious  diseases,  as  yellow  fever,  scarlet  fever, 
measles,  small-pox,  etc. 

11.  Weil's  disease  (epidemic  jaundice) ;  malignant  jaundice  (acute 
yellow  atrophy). 

12.  Phosphorus-poisoning. 

13.  Acute  jaundice  with  hemorrhage,  following  operation. 

14.  Erosions — postoperative  hematemesis  due  to  these ;  the  French 
describe  them  after  appendicitis  as  vomito-negro-appendiculaire. 

15.  Exulceratio  simplex  (Dieulafoy),  or  superficial  ulceration  of 
the  stomach. 

As  it  is  the  general  tendency  to  impute  cases  of  gastric  hemorrhage 
chiefly  to  ulcer  or  cancer,  it  seemed  desirable  to  classify  all  causes. 

Symptoms. — The  chief  symptoms  are  hematemesis  and  melena. 
Acute  anemia  develops  if  much  blood  is  lost ;  the  patient  feels  dizzy 

211 


212  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

and  weak  and  faints  easily.  The  sight  is  blurred,  pulse  rapid  and 
feeble,  and  extremities  cold;  rarely  convulsions  and  death  follow. 
Nausea  and  vomiting  occur.  The  blood  may  be  dark  in  color  or 
coffee  ground  in  appearance,  or  light  if  in  a  large  amount.  An 
evanescent  rise  of  temperature  may  occur  after  the  hemorrhage. 

At  times  the  symptoms  may  take  place  with  no  hematemesis 
and  nothing  definite  visible  in  the  stool,  when  Weber's  or  the  benzidin 
test  may  be  necessary  to  determine  the  presence  of  blood. 

Prognosis. — The  prognosis  is  rarely  fatal  from  the  hemorrhage 
itself,   but  depends  on  the  primary  disease. 

Treatment. — A  h^'-podermic  of  morphin,  gr.  ^  (0.016),  and  locall}^ 
the  ice-bag;  ext.  ergot  3ss  (2.0)  in  solution  by  hypodermic,  or  ernutin 
Ttlv  (0.3)  by  hypodermic,  and  in  addition  gelatin  10  per  cent,  solution, 
or  Tremoliere's  solution  gelatin,  5  per  cent,  with  calcium  chlorid,  2 
per  cent.  These  gelatin  preparations  should  be  given  from  5ij  to  oj 
(8.0-30.0)  every  half -hour  to  an  hour  by  mouth. 

Tannic  acid,  gr.  v  (0.33),  or  lactate  or  chlorid  calcium,  gr.  xv  (i.o), 
should  be  given  in  solution  (water  200  cc.  or  ovj)  by  rectum;  lactate 
of  strontium  or  magnesium,  gr.  xv  to  xxx  (1.0-2.0)  in  60  cc.  (oij) 
of  water  can  also  be  administered  by  hypodermic. 

Adrenalin  chlorid  (1:1000);  5  to  10  drops  (0.291-0.582  cc), 
by  mouth  or  hvpodermic  is  recommended,  but  it  at  times  too  rapidly 
increases  pulse  tension,  especially  if  given  hypodermically. 

Hypodermoclysis  or  the  rectal  injection^  of  normal  saline  at 
120°  F.  are  useful.  Ice-w^ater  lavage  in  rare  instances  may  be 
necessary.  Stimulants,  such  as  strychnin,  gr.  gV  (0.00108),  or 
camphorated  oil,  gr.  75  (0.5),  camphor  in  IU20  (1.3)  of  sterile  almond 
oil,  by  hypodermic,  may  be  required. 

ULCER  OF  THE  STOMACH 

{Synonyms. — Ulcus  Ventriculi  (Simplex);  Peptic  Ulcer;  Ulcus  Ventriculi  Rotun- 
dum;  Perforating  Gastric  Ulcer;  Cruveilhier's  Disease.) 

Ulcer  of  the  stomach  is  characterized  by  a  destruction  of  the 
mucous  membrane  of  the  stomach  varying  in  degree,  exhibiting  no 
tendency  to  heal,  and  in  typic  cases  attended  with  gastric  s^^mptoras 
associated  with  pain,  vomiting,  and  hematemesis.  It  was  first 
described  by  Cruveilhier  in  1829. 

Etiology. — Postmortem  and  Geographic  Distribiition. — Brinton 
found  evidences  of  gastric  ulcer  in  5  per  cent,  of  persons  dying  from 
all  causes,  most  frequent  in  London  and  on  the  Continent.  Gerhardt 
Iiotes  its  frequent  occurrence  in  Thuringia,  and  Von  Sohlern  its 
rarity  in  Russia,  the  Rhine  region,  and  in  the  Bavarian  Alps,  believing 
this  to  be  due  to  the  vegetarian  diet  (rich  in  potassium  salts)  in  these 
countries.     This  theor}^  lacks  scientific  confirmation. 

Sex. — Gastric  ulcer  occurs  more  in  women  than  in  men.     Welch 

^  Proctoclysis  is  of  value. 


ULCER   OF    THE    STOMACH  213 

places  it  at  60  per  cent,  in  women  and  40  per  cent,  in  men,  while 
Brinton  believes  it  twice  as  frequent  in  women. 

Age. — Cases  have  been  reported  in  children  under  ten  vears. 
It  occurs  most  frequently  between  twenty  and  forty  in  females,  and  in 
males  quite  often  between  forty  and  fifty.  Ewald  places  the  highest 
mortality  between  forty  and  sixty.     It  may  occur  in  old  people. 

Occupation. — Cooks,  shoemakers,  and  porcelain  makers  are  most 
liable  to  this  disease,  but  it  seems  a  matter  merely  of  coincidence. 

Traumatism. — Simple  trauma  probably  cannot  produce  gastric 
ulcer  unless  other  conditions  are  associated.  Blows,  falls,  and  the 
swallowing  of  foreign  bodies,  such  as  knives  by  jugglers,  etc.,  have 
produced  severe  damage  to  the  mucosa  of  the  stomach  and  marked 
hemorrhage,  without  the  ultimate  production  of  ulcer.  Griffini 
and  Vassale  have  resected  or  burned  out  portions  of  the  nmcosa  of 
the  stomachs  of  animals  and  perfect  healing  has  taken  place,  with  no 
ulceration.  Traumatism  may  be  a  factor,  as  is  shown  in  the  following 
case  of  mine:  Girl,  age  twenty-tw^o,  with  no  gastric  symptoms, 
was  thrown  from  a  trolley  car,  striking  on  the  epigastric  region. 
Pain  and  tenderness  were  present  at  this  point  and  gastric  symptoms 
developed.  There  was  no  visible  hemorrhage,  but  pain  and  symp- 
toms continued  for  six  weeks,  apparently  of  hyperchlorhydria,  but 
local  tenderness  persisted  at  the  point  of  injury.  The  patient  then 
had  a  sudden  gastric  hemorrhage  of  severe  type  and  the  ultimate 
course  w^as  of  ulcer  of  the  stomach.  Cure  resulted  in  eight  months, 
the  case  being  obser^^ed  for  several  years  subsequently,  with  no  recur-, 
rence.  This  girl  was  anemic  before  the  accident  and  probably 
hyperchlorhydria  was  present,  though  no  symptoms  were  complained 
of.  A  hematoma  was,  I  believe,  produced  in  the  stomach  wall,  inter- 
fering with  its  nutrition,  and  the  other  conditions  favored  ulcer  devel- 
opment. The  patient  also  had  a  hematoma  of  the  thigh  from  the 
same  accident.     Traumatism  under  such  conditions  may  be  a  factor. 

Anemia  and  chlorosis  may  predispose  to  ulcer,  and  Riegel  and 
Charles  Stockton  have  shown  that  hyperchlorhydria  frequently 
accompanies  these  conditions,  and  that  it  has  an  influence  in  the 
prevention  of  the  cure  of  ulcer  or  even  in  its  production.  Experi- 
ments on  animals  have  been  performed  for  the  purpose  of  studying 
the  etiolog}^  of  ulcer.  Quincke  and  Daettwyler  made  animals  anemic 
by  venesection  and  produced  lesions  in  the  gastric  mucosa.  Section 
of  the  spinal  cord,  with  the  introduction  of  h  of  i  percent,  hydrochloric 
acid  solution  in  the  stomach  of  a  dog,  has  produced  ulceration  (Koch 
and  Ewald).  It  has  occurred  after  injury  to  the  anterior  corpora 
quadrigemina. 

Weinland  recently  maintains  that  there  is  formed  in  the  gastric  mucosa  an  anti- 
body, an  antipepsin,  which  opposes  the  digestive  action  of  the  acid  gastric  juice. 
If  the  antibody  is  deficient  in  a  certain  area,  this  unprotected  region  is  readily 
injured  by  the  gastric  juice.  Rosenau  has  produced  gastric  ulcer  by  the  injection 
of  diphtheria  toxin.  Botton  has  produced  gastric  ulcer  in  animals  by  injecting 
the  macerated  gastric  mucosa  of  other  animals  and  of  animals  of  other  species. 


214  DISEASES   OF   THE   STOMACH  AND   INTESTINES 

The  neurotrophic  theory  has  been  held  by  some.  Stockton 
beHeves  that  nerve  perturbation  analogous  to  herpes  may  be  a 
factor;  and  de  la  Verdora  produced  ulcer  and  hyperchlorhydria  by 
injecting  alcohol  into  the  splanchnic  and  celiac  plexus  of  a  dog. 
Section  of  the  vagi  below  the  diaphragm  has  caused  ulceration  of  the 
gastric  mucosa.  These  experiments  suggest  that  the  nervous  sys- 
tem may  be  a  factor. 

Silberman  introduced  substances  into  the  blood  producing 
hemolysis  (hemoglobinemia)  with  resulting  anemia,  and  found  that 
defects  of  the  mucosa  healed  tardily.  Turck  has  produced  gastric 
ulcer  by  feeding  dogs  with  pure  cultures  of  the  bacterium  coli 
comnmne.  It  is  known  that  burns  of  the  abdomen  may  produce 
gastric  ulcer,  though  usually  the  duodenum  is  affected, 

Pavy  held  the  theory  of  diminished  alkalinity  of  the  blood,  but 
this  can  hardly  be  accepted.  Erosions  have  been  considered  by 
some  to  be  the  cause  of  ulcers,  but  Langerhans  opposed  this  from 
his  experience  in  autopsies,  and  Einhorn  has  demonstrated  that 
gastric  erosions  are  a  clinical  entity  and  that  ulcer  does  not  result. 
We  know  that  autodigestion  of  the  gastric  mucosa  occurs  after  death. 
The  effect,  therefore,  of  circulatory  disturbances  of  the  blood-vessels 
of  the  stomach  in  the  development  of  ulceration  is  important. 

Virchow  first  suggested  that  ulceration  may  result  from  the 
plugging  of  a  nutrient  artery  to  part  of  the  mucosa  by  a  thrombus 
or  embolus,  and  that  the  infarction  is  destroyed  by  the  gastric  juice. 
Panum  supported  this  view  by  producing  infarcts  and  ulcers  of  the 
stomach  in  a  dog  by  injecting  an  emulsion  of  wax  into  the  femoral 
artery.  Occlusion  of  the  portal  vein  or  of  some  of  the  large  veins 
of  the  stomach  may  cause  gastric  ulcer. 

Injection  of  chromate  of  lead  into  the  gastric  and  splenic  arteries 
(Cohnheim)  has  produced  ulcer.  Talma,  by  increasing  the  tension 
of  the  gastric  wall  by  ligating  the  orifices  of  the  stomach,  has  brought 
about  ulceration.  Artificial  anemia  by  faradization  of  the  stomach 
has  caused  ulcer.  Local  interference  with  the  circulation,  with  resulting 
necrosis,  associated  with  hyp^chlorhydria  and  changes  in  the  blood 
are  probably  the  most  frequent  causes. 

Hyperchlorhydria  is  present  in  about  95  per  cent,  of  the  cases,^ 
but  occasionally  there  is  subacidity  or  achylia  gastrica,  as  reported 
by  Einhorn  and  others.  I  have  recently  seen  a  case  with  very  low 
acidity  (Connor's  case).^  Probably  gastric  ulcer  is  not  always 
produced  by  the  same  factors,  and  several  of  the  theories  described 
may  apply.  Hyperchlorhydria  undoubtedly  has  a  bearing  on  most 
cases,  and  frequently  anemia  or  chlorosis. 

Morbid   Anatomy. — The  peptic  ulcer  is  found   in  the  regions 

1  Recent  reports  from  Mayo's  cases  show  there  are  quite  a  number  without 
marked  increase  in  HCl. 

2  Frequent  gnstric  analyses  showed  free  HCl  trace  or  absent;  lactic  acid 
present;  microscopic  pus  and  occult  blood.  Multiple  ulcers  (non-malignant)  were 
found  by  John  Connor  at  operation. 


ULCER   OF   THE    STOMACH  215 

exposed  to  the  gastric  juice,  in  the  stomach,  lowest  part  of  the 
esophagus,  and  upper  duodenum.  It  is  round  or  oval,  occasionally 
oblong;  is  funnel  shaped,  the  upper  part  being  the  larger;  is  of 
variable  depth,  its  floor  being  formed  by  the  subniucosa,  muscular 
tissue,  serosa,  or  by  adjacent  adherent  organs.  The  acute  ulcer  is 
usually  small,  punched  out,  with  clean  cut  edges  and  a  smooth  floor, 
with  no  thickening  of  the  peritoneal  coat ;  occasionally  the  floor  may 
be  covered  with  a  thick  green  or  brown  mucus. 

The  chronic  ulcer  is  of  larger  size,  with  callous  margins,  and  the 
border  may  be  sinuous.  It  is  often  markedly  indurated,  so  if  situated 
at  the  pylorus  it  may  feel  like  a  tumor  on  palpation. 

Embolism  or  endarteritis  of  the  artery  supplying  the  ulcerated 
region  has  been  found,  or  a  small  aneurism  on  the  floor  of  the  ulcer. 

Microscopically. — The  ducts  of  the  glands  are  cut  off  toward  the 
base,  being  eaten  away  or  digested  up  to  where  the  tissue  offers 
sufficient  resistant  power  to  the  gastric  juice. 

Healing  occurs  by  proliferation  of  the  connective  and  glandular 
tissue  near  the  margin  of  the  gland.  As  the  connective  tissue  con- 
tracts, the  proliferation  of  the  glands  is  stopped.  If  the  stomach 
wall  is  adherent  to  an  adjacent  organ  and  the  ulcer  perforates,  the 
neighboring  tissue  may  grow  into  the  hole  and  unite  with  the  con- 
nective tissue  growing  from  within.  Muscle-fibers  do  not  regenerate. 
This  is  true  of  the  large  deep  ulcers ;  the  mucosa  and  m.uscularis  roll 
in  and  adhere  to  the  adjacent  organ.  There  is  further  proliferation 
of  tissue  caused  by  irritation  of  the  gastric  juice,  and  the  latter  may 
cause  erosion  of  vessels. 

The  rest  of  the  imicous  membrane  of  the  stomach,  as  a  rule,  remains 
normal. 

Extent  of  the  Ulcer. — It  may  vary  from  the  size  of  a  pea  to  a 
diameter  of  5  or  6  inches;  the  average  being  from  a  5-cent  piece  to 
a  25-cent  piece.     Peabod}"  reports  one  measuring  19  by  10  cm. 

Location. — It  is  commonly  situated  on  the  posterior  wall  of 
the  pyloric  end  of  the  stomach,  at  or  near  the  lesser  curvature. 
Welch  states  that  out  of  793  cases,  288  were  in  the  lesser  curvature, 
95  at  the  pylorus,  96  on  the  anterior  wall,  50  at  the  cardia,  29  at  the 
fundus,  and  27  on  the  greater  curvature.     Other  statistics  are  given. 

Number, — In  about  80  per  cent,  of  cases  i  ulcer  is  found;  in  a 
trifle  over  one-half  the  remainder,  2  ulcers;  in  the  balance,  3  to  5 
ulcers;  Osier  reports  34  ulcers  in  i  case,  and  Lange  i  in  which  he 
could  not  count  them. 

Progress  of  the  Ulcer. — i.  Cicatrization  may  occur,  with 
formation  of  a  connective-tissue  scar,  w^hich  tends  to  depress  and 
contract.  Depending  on  its  location,  it  may  cause  stricture  of  the 
pylorus,  esophagus,  or  an  hour-glass  stomach.  In  other  situations 
it  may  produce  no  trouble. 

2.  Progressive  necroses  may  take  place  and  there  may  result: 

(a)  Erosion  of  a  blood-vessel  with  severe  or  occasionally  fatal 


2l6  DISEASES   OF  THE   STOMACH  AND  INTESTINES 

hemorrhage  from  perforation  of  a  large  vessel,  such  as  the  gastric, 
hepatic,  or  splenic  artery,  portal  vein,  etc. 

(b)  Adhesions  to  neighboring  organs  or  various  perforations. 
The  stomach  may  become  adherent  to  the  liver,  gall-bladder,  spleen, 
pancreas,  or  intestines,  and  there  may  be  perforation  into  these 
organs. 

If  the  ulcer  is  on  the  anterior  surface,  then  direct  perforation  and 
general  peritonitis  may  follow. 

There  is  sometimes  a  circumscribed  peritonitis  when  adhesions 
form  with  other  organs  and  a  local  abscess,  which  may  later  perforate 
into  the  peritoneal  cavity. 

The  ulcer  may  perforate  into  the  lesser  peritoneal  cavity  and 
cause  subphrenic  abscess;  the  diaphragm  may  be  perforated  and  a 
communication  formed  with  the  pleura,  lungs,  pericardium,  and 
even  with  the  left  ventricle;  or,  rarely,  an  emphysema  of  the  sub- 
peritoneal tissue  occurs,  which  may  pass  into  the  posterior  medias- 
tinum; or  adhesions  may  form  and  a  perforation  of  the  anterior 
abdominal  wall  take  place ;  or  general  emphysema  of  the  subcutaneous 
tissues  may  rarely  result. 

In  cases  with  adhesions  to  adjacent  organs,  with  or  without 
abscess,  localized  growing  tumors,  hard  in  consistency,  may  be 
formed,  and  Gerhardt  notes  the  possibihty  of  mistaking  these  for 
carcinoma,  but  the  history  and  gastric  analysis  make  the  diagnosis. 

Symptoms.^ — Some  cases  present  typic  symptoms,  in  which 
event  the  diagnosis  is  easy;  others  suffer  apparently  from  a  simple 
hyperchlorhydria  for  a  long  period  of  time  with  no  special  symptoms 
pointing  to  ulcer;  while  in  others  the  condition  is  latent. 

In  the  latent  cases  the  patient  is  sometimes  apparently  perfectly 
well,  when  there  will  suddenly  develop  hematemesis  or  symptoms  of 
perforative  peritonitis.  Others  may  not  vomit,  but  suddenly  turn 
faint  and  weak,  become  pale  with  a  feeble  pulse,  presenting  the 
symptoms  of  internal  hemorrhage.  Examination  of  the  stool  for 
occult  (concealed)  hemorrhage  by  Weber's,  the  aloin,  or  the  benzidin 
test  is  a  valuable  aid. 

Cases  Simulating  Hyperchlorhydria. — Kaufmann,^  of  New  York, 
has  suggested  that  in  cases  of  hyperchlorhydria  not  yielding  to 
treatment  and  in  whom  the  pain  is  of  a  gnawing  or  tearing  character 
the  suspicion  of  ulcer  is  justified.  This  is  undoubtedly  true,  and 
repeated  examinations  of  the  gastric  contents  and  stool  for  blood 
or  occult  blood  are  indicated. 

Typical  Case. — As  a  rule,  the  symptoms  of  gastric  ulcer  develop 
slowly  and  are  as  follows:  at  first  a  feeling  of  fulness  and  pressure 
after  eating;  gradually  increasing  to  pain  in  the  epigastrium,  which 
may  become  so  severe  that  the  patient  is  afraid  to  eat.  Nausea, 
regurgitation,  or  vomiting  may  occur  early. 

iNew  York  Medical  Journal  and  Philadelphia  Medical  Journal,  March  ii, 
1905. 


ULCER    OF   THE    STOMACH  217 

Pain  occurs  generally  a  few  minutes  after  eating,  though  sometimes 
one-half  to  one  hour  later,  and  persisting  during  digestion.  Coarse 
substances  and  large  quantities  of  food  increase  it.  It  is  of  a  burning 
or  gnawing  character.  Epigastric  pain  is  increased  on  pressure  and 
the  sensitive  point  is  usually  circumscribed. 

A  few  weeks  later  dorsal  pain  begins,  gnawing  in  character,  lying 
to  the  left  of  the  spine,  between  the  eighth  and  tenth  vertebrae, 
alternating  with  the  epigastric  pain;  at  times  there  is  sensitiveness 
on  pressure  in  this  region. 

The  epigastric  pain  is  not  continuous,  as  in  cancer,  but  there  are 
periods  of  relief.  Later,  vomiting  may  occur,  one  to  two  hours  after 
meals,  of  very  acid  watery  material,  mixed  with  food ;  emesis  generally 
relieves  the  pain;  occasionally  there  is  vomiting  late  at  night  or  early 
in  the  morning  if  gastrosuccorrhea  (hypersecretion)  is  associated  with 
ulcer. 

Appetite  is  variable;  at  times  the  patient  desires  food,  but  fears 
to  eat  on  account  of  pain ;  constipation  generally  marked ;  amenorrhea 
frequent  in  women;  anemia  marked  in  many  cases. 

These  symptoms  continue,  then  hemorrhage  suddenly  occurs,  and 
is  visibly  present  in  one-third  to  one-half  the  cases,  and  in  a  very 
large  percentage  when  occult  hemorrhage  is  included,  as  it  should  be. 

(i)  Hemorrhage  may  he  occult,  no  vomiting  of  blood,  the  patient 
turning  pale  and  faint  and  in  a  cold  sweat,  and  on  the  next  day  there 
are  tarry  stools,  or  occult  blood  is  found  in  the  stool  by  Weber's  or 
the  benzidin  test.  Progressive  anemia  may  be  caused  by  small 
repeated  hemorrhages. 

(2)  The  patient  may  experience  a  sense  of  fulness  after  a  meal  and 
become  nauseated  and  restless;  then  hematemesis  occurs  in  large 
amount,  of  fluid  blood,  bright  red,  or  of  liver  color,  brown,  or  coffee 
grounds,  mixed  with  food. 

Patient  may  feel  faint,  extremities  cold,  temperature  subnormal, 
become  collapsed  and,  rarely,  even  die  from  hemorrhage.  Con- 
vulsions and  unconsciousness  may  precede  death.  Death  from 
internal  hemorrhage  can  occur  without  vomiting.  Blood  is  generally 
passed  by  the  stools  (melena) ,  black  and  tarry  in  color,  and  may  be 
found  in  cases  with  no  vomiting  or  in  latent  cases. 

Convulsions  from  cerebral  anemia,  or  hemiplegia  from  thrombosis, 
or  amaurosis  (possibly  permanent)  have  occurred.  A  temporary 
rise  of  temperature  may  follow  the  collapse.  Persistent  temperature 
shows  complications.  The  vomitus  usually  shows  hyperchlorhydria 
and  no  mucus.     Tongue  is  clean  and  red,  rarely  coated. 

Often  there  are  remissions  and  exacerbations  of  the  symptoms, 
and  they  may  be  protracted ;  from  no  apparent  cause  a  relapse  may 
occur.  With  an  unhealed  ulcer,  complications  or  perforation  may 
occur  at  any  time.  In  others,  ulcer  symptoms  may  disappear,  but 
those  of  gastric  dilatation,  adhesions,  etc.,  may  follow.  In  the  long 
cases,  from  pain  and  self-starvation,  marked  emaciation  takes  place; 


2l8  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

the  suffering  shows  in  the  patient's  face,  but  there  is  not  the  sallow- 
appearance  of  cancer.  Tetanic  attacks  complicating  chronic  ulcer 
have  been  reported  by  Kaufmann.^ 

Pain. — The  epigastric  pain  usually  occurs  about  the  center  of  this 
region,  in  the  median  line,  just  below  the  tip  of  the  ensiform.  Occa- 
sionally it  is  more  to  the  right  or  left,  and  Hes  in  a  circular  area  of  i  to 
2  inches  in  diameter.  Throbbing  and  pulsation  may  be  felt  in  the 
epigastrium.  Pain  is  usually  increased  on  pressure,  rarelv  lessened. 
It  is  injurious  to  frequently  manipulate  the  painful  area  or  subject 
it  to  marked  pressure.     Testing  with  the  algesimeter  is  not  advisable. 

In  place  of  vomiting,  some  patients  regurgitate  acid  chyme,  with 
pyrosis,  or  suffer  from  nausea. 

Motor  Function. — In  uncomplicated  cases  of  gastric  ulcer  this  is 
increased.  If  pyloric  stenosis  or  adhesions  compHcate,  then  the 
function  is  interfered  with. 

Examination  of  the  Stomach  Contents. — If  the  diagnosis  of  ulcer 
has  been  positively  determined,  it  is  preferable  not  to  pass  the  tube. 
If  there  is  no  hematemesis,  but  vomiting  is  excessive,  it  is  well  to 
give  the  test  meal  and  examine,  in  addition,  for  occult  blood.  Lav- 
age after  the  contents  are  removed  is  of  service,  as  it  checks  emesis, 
and  thus  renders  a  hemorrhage  less  liable. 

If  the  patient  states  there  has  been  a  hemorrhage,  but  the  diagnosis 
is  in  doubt,  the  tube  should  not  be  passed  earher  than  ten  days  to 
two  weeks  after  the  history  of  hematemesis.  The  stool  can  be  exam- 
ined at  once  for  occult  blood. 

If  vomiting  occurs,  the  vomitus  ma^/  be  examined  by  preference, 
but  the  quantity  and  quality  of  the  food  and  time  of  ingestion  would 
influence  the  analytic  findings  and  might  lead  to  error.  Immediate 
examination  of  the  vomitus  and  stool  for  occult  blood  is  important. 

In  about  95  per  cent,  of  uncomplicated  cases  of  ulcer,  hyper- 
chlorhydria  is  present;  the  total  acidity  is  high,  from  90+  to  150  +  , 
and  free  hydrochloric  acid  50+  to  60 -1-  or  even  90  +  ,  and  there  is 
no  mucus. 

There  are  cases  of  subacidity,  or  even  of  achylia  gastrica,  with 
ulcer. 

The  Absence  of  Hyperchlorhydria  Does  Not  Exclude  the  Presence 
of  Ulcer. — In  all  doubtful  cases  gastric  analysis  and  examination 
for  occult  blood  in  the  stomach  contents  and  stool  should  be  carried  out. 

In  some  cases  we  must  think  of  the  possibility  of  development 
of  carcinoma  on  the  base  of  an  ulcer,  but  in  such  event  tumor  growth 
and  increasing  cachexia  occur. 

Urtne. — The  quantity  is  reduced  when  there  is  much  vomiting 
and  food  is  diminished.     There  are  no  characteristic  changes. 

Complications. — Perforation    and    general    peritonitis;    circum- 
scribed peritonitis ;  sacculated  abscess ;  adhesions  with  other  viscera, 
with  or  without  perforation  of  them ;  pyloric  stenosis ;  stenosis  of  the 
'  American  Journal  of  the  Medical  Sciences,  April,  1904. 


ULCER   OF   THE    STOMACH  219 

cardia;  perigastritis  with  adhesions;  subphrenic  abscess;  perforation 
of  the  diaphragm,  pleura,  lungs,  pericardium  or  heart;  hour-glass 
contraction  of  the  stomach;  external  fistulous  opening;  anemia  of 
severe  type;  mediastinal  emphysema,  and  subcutaneous  emphysema 
may  occur. 

Stenosis  of  the  pylorus,  due  to  stricture  or  hypertrophy  from 
spasm,  produce  dilatation  of  the  stomach  and  its  symptoms;  stenosis 
of  the  cardia  causes  dysphagia  and  regurgitation  of  food. 

Perforation. — This  occurs  in  ulcers  on  the  anterior  stomach  wall, 
or  from  perforation  of  a  circumscribed  abscess,  with  resulting  general 
peritonitis.  The  symptoms  are  sudden  pain,  at  times  with  a  tearing 
sensation,  shock,  muscular  rigidity,  rapid  distention  of  the  abdomen; 
tenderness  on  pressure;  disappearance  of  liver  dulness;  cold  sweat; 
rapid  and  feeble  pulse,  followed  by  a  rise  of  temperature,  singultus; 
frequently  vomiting ;  anxious  and  sunken  face  (f acies  Hippocratica) ; 
usually  coma;  then  death.  Leukocytosis,  especially  increase  in  the 
polynuclears,  is  present. 

In  perforation,  with  circumscribed  abscess  formation,  the  symp- 
toms are  less  intense  and  are  localized.  Perforation  of  the  stomach 
occurs  usually  after  a  full  meal,  or  following  coughing,  sneezing,  or 
local  mechanic  violence. 

If  adhesions  form  with  other  organs,  these  may  be  perforated. 

Frequency  of  Perforation. — Brinton  gives  the  frequency  of  per- 
foration as  I  in  8  cases.     Others  place  it  at  6  to  7  per  cent. 

In  women,  Brinton  places  one-half  the  perforations  at  the  age 
of  fourteen  to  thirty,  the  average  being  twenty-seven ;  while  in  men 
it  is  distributed  up  to  fifty,  the  average  age  being  forty-two. 

The  chances  of  perforation  of  an  ulcer  on  the  anterior  stomach 
wall  are  5  to  i  in  its  favor,  on  account  of  its  mobility  which  prevents 
adhesion  formation,  but  ulcers  are  much  less  frequent  .in  this  location. 

Subphrenic  abscess  (pyopneumothorax  subphrenicus,  when  gas 
is  present). 

Etiology. — The  chief  causes  are  as  follows :  Posterior  perforating 
ulcer  of  the  stomach  (the  most  frequent  cause) ;  traumatism  of  the 
liver;  abscess  of  the  liver;  retroverted  appendix;  and  perforation  of 
duodenal  ulcer. 

The  boundaries  of  the  abscess-cavity  are:  above,  the  diaphragm; 
below,  the  stomach  and  liver;  to  the  left,  the  spleen;  to  the  right,  the 
suspensory  ligaments  of  the  liver.  The  liver  is  pushed  down  and 
the  diaphragm  upward. 

Symptoms. — These  are  abrupt  when  due  to  perforation  of  gastric 
ulcer  and  are  as  follows :  severe  pain ;  vomiting  of  bilious  or  bloods- 
material;  embarrassment  of  respiration;  subsequently  chills,  fever, 
and  emaciation.  Leukocytosis  and  increased  polynuclears  during 
the  suppurative  period. 

Physical  signs  depend  on  the  quantity  of  air  in  the  cavity  and 
upon  the  presence  or  absence  of  a  complicating  pleurisy. 


220  DISEASBS    OF   THE    STOMACH   AND   INTESTINES 

Physical  Signs  (with  Little  Air  Present). — Dulness  or  flatness  in 
the  lower  part  of  the  thorax,  but  cough  and  expectoration  are  absent; 
signs  of  pressure  in  the  pleural  cavity  are  absent  or  slight,  the  thorax 
not  being  much  dilated,  and  there  being  scarcely  any  obUteration 
of  the  intercostal  spaces;  the  lungs  are  intact  and  distensible,  and 
on  deep  inspiration  there  is  vesicular  breathing. 

Physical  Signs  (with  Much  Air  Present). — The  lower  part  of  the 
thorax  protrudes  and  respiratory  movements  diminish;  the  heart 
is  sometimes  pushed  upward  and  slightly  to  the  right;  the  liver 
extends  well  down  into  the  abdomen,  occasionally  as  far  as  the  umbilicus; 
the  liver  dulness  in  the  back  and  lower  part  of  the  lung  is  replaced 
by  a  tympanitic  zone;  on  auscultation  the  respiratory  sounds  are 
absent  in  this  zone,  and  there  are  succussion  sounds  of  a  metallic 
pitch. 

When  pleurisy  complicates  subphrenic  abscess  from  ulcer,  there 
are  the  signs  of  pleurisy.  Senator  gives  the  following  diagnostic 
points : 

Violent  pain  in  the  epigastric  and  hypochondriac  region ;  pain  in 
the  back  on  sitting  up;  pain  on  belching;  patients  prefer  dorsal 
position  when  abscess  complicates;  while  in  pleurisy  alone,  they  lie 
on  the  diseased  side;  edema  of  the  lower  lateral  and  posterior  tho- 
racic walls. 

Pfuhl  suggests  a  diagnostic  point  between  subphrenic  abscess 
and  pyopneumothorax. 

In  subphrenic  abscess,  if  an  aspirating  needle  be  inserted  and  a 
manometer  be  attached,  the  pressure  is  greater  on  inspiration  and 
less  on  expiration. 

In  pyopneumothorax  the  pressure  conditions  are  reversed. 

Exploratory  puncture  is  the  accurate  method  of  diagnosis,  pus 
and  food  particles  being  aspirated. 

Terminations  of  Subphrenic  Abscess. — Perforation  of  the 
diaphragm  and  pleura;  perforation  of  the  lung,  with  expectoration 
of  pus ;  or  of  the  pericardium. ;  or  of  the  left  ventricle ;  or  of  the  colon ; 
rarely  perforation  into  the  general  peritoneum ;  or  perforation  of  the 
skin,  with  resulting  fistula. 

Successful  operations  have  been  performed  for  subdiaphragmatic 
abscess,  notably  by  Carl  Beck.'^  Tuberculosis  may  occur  in  asso- 
ciation with  ulcer. 

Some  authors  describe  so-called  atypic  forms  of  ulcer,  taking  the 
most  prominent  symptom  as  a  basis,  such  as :  Gastralgic.  Catarrhal 
or  vomiting.  Dyspeptic  or  latent.  Hemorrhagic.  Cachectic.  Per- 
forative form. 

Diagnosis. — This  is  easy  in  the  typic  form  characterized  by 
hematemesis,  the  epigastric  pain  circumscribe'd,  and  present  dur- 
ing the  digestive  process,  the  dorsal  pain,  local  tenderness,  and 
vomiting. 

1  Medical  Record,  Feb.  5,  1896. 


ULCER   OF   THE   STOMACH 


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ULCER    OF   THE    STOMACH  223 

Other  conditions  have  been  mistaken  for  gastric  ulcer.  Gastric 
crises  of  locomotor  ataxia;  absence  of  patellar  reflexes;  Rhomberg 
symptom  and  the  Argyll-Robertson  pupil  are  diagnostic. 

Duodenal  Ulcer. — This  is  at  times  impossible  to  differentiate, 
especially  if  the  ulcer  is  near  the  pylorus.  It  occurs  most  frequently 
■in  males;  is  often  latent ;  melena  is  frequent ;  pain  and  tenderness  are 
often  a  little  more  to  the  right  than  in  gastric  ulcer;  no  dorsal  pain; 
hematemesis  not  as  frequent ;  pain  after  the  ingestion  of  food  is  usually 
later  than  in  gastric  ulcer.     Occult  blood  most  frequent  in  stool. 

Spider  Gall-bladder  Adhesions. — Robert  T.  Morris  has  demon- 
strated that  gastric  hemorrhage  occurs  at  times  with  this  condition. 
The  stornach  is  dilated,  and  the  diagnosis  has  been  made  of  stenosis 
of  the  pylorus  with  ulcer. 

There  is  a  previous  history  of  gall-bladder  disease  in  these  cases. 
The  possibility  of  this  condition  must  be  considered. 

Cirrhosis  of  the  Liver. — Severe  gastric  hemorrhage  may  occur, 
but  examination  of  the  liver,  the  history,  and  other  symptoms  will 
differentiate. 

Location  of  the  Ulcer. — Occasionally  one  can  make  a  probable 
diagnosis  as  to  the  position  of  the  ulcer;  if  relief  is  afforded  when 
standing,  the  ulcer  is  probably  on  the  lesser  curvature;  if  pain  is 
intense  on  standing,  it  is  on  the  greater  curvature ;  if  less  severe  pain 
when  lying  on  left  side,  the  ulcer  is  probably  at  the  pylorus,  etc. 
The  position  which  affords  most  comfort  to  the  patient  is  the  one 
which  permits  the  idcer  to  remain  above  the  gastric  contents. 

Einhorn^  has  recently  described  two  methods  for  recognizing  and 
locaUzing  gastric  ulcers:  the  so-called  "thread  impregnation  test," 
in  which  the  patient  swallows  the  duodenal  bucket  with  thread  attach- 
ment, which  is  removed  twelve  hours  later.  Blood  discoloration  on 
the  string  shows  the  presence  of  ulcer,  and  the  distance  of  this  spot 
from  the  teeth,  its  location.  His  second  method,  by  the  "gastric 
stamper,"  consists  in  the  introduction  of  a  collapsed  balloon  into  the 
stomach,  which  is  then  distended  and  secures  an  impression  of  blood 
from  the  ulcer.  It  is  then  deflated  and  removed.  Both  methods 
are  uncertain,  and  pressure  from  inflation,  I  believe,  dangerous.  The 
use  of  the  gastroscope  to  locate  the  ulcer  is  a  risky  procedure.  The 
presence  of  blood  or  occult  blood  in  the  gastric  contents,  vomitus,  or 
stool,  together  with  the  methods  of  diagnosis  previously  described, 
are  sufficient. 

Course. — Gastric  ulcer  occasionally  runs  a  rapid  course  with 
death  from  perforation  or  hemorrhage.  StowelP  states  that  i8  per 
cent,  last  a  year  or  less;  46.5  per  cent.,  from  one  to  six  years.  A  case 
of  thirty  years'  duration  has  been  reported.  There  are  often  inter- 
missions of  improvement  and  exacerbations;  or  the  patient  may 
become  a  chronic  invalid. 

1  Medical  Record,  April  3,  1909. 

2  Ibid.,  July  8,  1905. 


224  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

Prognosis. — Excepting  the  fulminating  cases,  the  more  recent 
the  ulcer,  the  more  favorable  the  prognosis  as  to  cure. 

The  mortality  has  been  estimated  at  from  8  to  lo  per  cent. ;  some 
place  it  up  to  20  per  cent.  The  position  of  the  ulcer  modifies  the 
prognosis;  if  on  the  anterior  wall,  perforation  is  more  apt  to  occur; 
if  the  pylorus  is  involved,  stenosis  and  dilatation  of  the  stomach 
result;  if  hypersecretion  be  associated,  the  results  are  less  favorable. 
Stowell's  statistics  are  as  follows: 

Death  from  hemorrhage,  3  to  4  per  cent. ;  from  exhaustion, 
5  per  cent.;  from  fatal  perforation,  6.5  to  13  per  cent.  Pulmonary 
tuberculosis  was  the  terminal  event  in  20  per  cent.  (Debove  and 
Remond)  out  of  100  cases  investigated. 

Treatment. — For  Hemorrhage  {Hematemesis). — Absolute  rest  in 
the  dorsal  position ;  immediate  injection  of  morphin  sulphate,  gr.  \  to 
\  (0.008-0.016),  and  the  application  of  a  light  ice-bag  over  the 
stomach,  if  necessary,  suspended  from  a  barrel  hoop  to  avoid  weight. 
In  emergency  I  have  tied  bits  of  ice  in  a  sheet  of  rubber  tissue  or  in 
dress  shields. 

One  to  two  teaspoonfuls  of  a  5  to  10  per  cent,  solution  of  gelatin 
(cold),  depending  on  the  severity  of  the  case,  should  be  given  by 
mouth  every  half -hour  for  ten  to  twelve  hours,  even  if  vomiting. 
This  is  an  excellent  hemostatic,  and  also  takes  up  the  free  acid. 

The  frequent  administration  of  small  quantities  is  preferable  to 
larger  amounts  given  every  two  or  three  hours. 

Gelatin,  100  cc.  (oiij)  of  a  2  per  cent,  solution  by  hypodermic 
with  a  large  syringe,  given  between  the  lowest  rib  and  crest  of  the 
ileum,  is  of  value. 

Ernutin  (Borrows  and  Welcome),  TTLv  to  x  (0.33-0.66),  by 
hypodermic,  or, 

I^.     Ext.  ergot gr.  XV  (i.o) 

Glycerini    1  ^^        - ;  ^ ,  ^\ 

,   ■'     ,        .,     >  aa         o  1     4..O) 

Aq.  destil.  J  ^■'^    ^ 

by  a  large  syringe  subcutaneously  have  proved  useful  adjuncts;  or 
fluidextract  of  ergot  or  hydrastis,  5j  to  ij  (4.0-8.0),  in  2  ounces  of 
water  by  rectum. 

Chlorid  of  iron  and  acetate  of  lead  are  objectionable. 

Tremoliere  has  recently  advocated  a  solution  as  a  local  styptic 
consisting  of  a  5  per  cent,  gelatin  solution  containing  2  per  cent. 
chlorid  of  calcium.  In  a  severe  case  I  should  not  hesitate  to  give 
at  once  by  mouth  i  to  2  ounces  of  a  10  per  cent,  gelatin  solution 
containing  5  to  10  gr.  (0.3  to  0.6)  of  chlorid  or,  preferably,  lactate 
of  calcium. 

The  drug  is  dissolved  in  a  little  water  and  added  to  the  gelatin 
solution  while  still  warm  and  then  rapidlv  cooled  off  on  ice. 

The  plain  gelatin  solution  should  be  admmistered  in  every  case. 

Lactate,  or  chlorid  of  calcium,  gr.  x  to  xv  (0.66-1.0),  in  oiv  (125 
cc.)  warm  water  can  be  given  by  enema  as  an  adjuvant. 


ULCER   OF  THE   STOMACH  225 

Lactate  of  strontium,  or  lactate  of  magnesium,  gr.  xv  to  xxx 
(i.o-2.o),  in  oij  to  iij  (125  cc.  to  200  cc.)  of  sterile  water,  are  rec- 
ommended by  hypodermoclysis,  by  Maas,  to  increase  the  coagulabilit)^ 
of  the  blood,  and  would  be  valuable  in  gastric  hemorrhage.  Calcium 
chlorid  should  never  be  so  given,  as  it  causes  local  coagulation 
necrosis,  and  the  lactate  of  calcium  never  stronger  than  i :  20  by 
hypodermic,  and  even  so  there  is  danger. 

Adrenalin  chlorid,  1:1000,  TTLx  to  xv  (0.66-1.0),  have  been 
recommended  by  hypodermic  for  internal  hemorrhage,  but  the  pulse 
tension  is  markedly  increased  thereby  and  I  have  seen  secondary 
hemorrhage  result.  Five  drops  may  be  given  by  the  mouth  in 
oij  (S.o)  of  w^ater  for  the  local  st^^ptic  effect  if  other  remedies  are 
insufficient. 

Bismuth  subnitrate,  oss  (2.0),  in  i  ounce  of  water  is  at  times  of 
service. 

Ewald  recommends  cautious  lavage  with  ice-water  after  cocainiz- 
ing the  pharynx  (2  per  cent,  solution  of  cocain  is  sufficiently  strong 
by  spray) ,  in  cases  in  which  death  seemed  imminent  from  continuous 
hemorrhage.  I  have  never  found  the  procedure  necessary,  though 
I  have  treated  severe  cases.  If  it  is  employed,  the  addition  of 
125  cc.  (oiv)  of  a  5  per  cent,  gelatin  solution,  gr.  xv  (i.o)  lactate  of 
calcium,  and  HIx  (0.66)  adrenalin  to  the  water  for  lavage  would  be 
of  advantage. 

Wiel  advises  lavage  with  hot  water  at  42°  C,  but  I  doubt  its 
advisability.  When  all  methods  fail  and  the  hemorrhage  continues, 
opening  the  stomach  and  direct  suture  of  the  bleeding  ulcer  has  been 
advocated. 

For  Thirst.— Th^  cold  gelatin  given  for  hemorrhage  helps  relieve 
thirst.  A  small  piece  of  gauze  dipped  in  cold  water  and  held  in  the 
mouth,  frequent  washing  of  the  latter;  an  occasional  pellet  of  ice  and 
enemata  of  normal  saline  solution  at  105°  F.,  oiv  to  vj  (125  cc.  to 
200  cc),  if  no  relief  by  other  methods,  and  given  every  three  hours. 

Proctoclysis,  the  administration  of  saline  solution  per  rectum  by 
the  drop  method,  is  also  useful. 

Gollapse.—Q.2iMt\on  must  be  employed  not  to  overstimulate  the 
heart,  lest  the  coagulum  be  forced  out  and  hemorrhage  recur. 

Only  collapse  that  is  fairly  marked — a  pulse  120  or  over — should 
be  treated,  as  depression  of  the  pulse  favors  clotting.  Among  the 
valuable  methods  are : 

External  application  of  heat  to  the  limbs  by  hot- water  bags; 
rectal  injections  of  i  pint  (500  cc.)  to  i  quart  (liter)  of  hot  normal 
salt  solution  at  1 1 5  °  to  1 20  °  F.  every  two  to  three  hours,  also  proc- 
toclysis can  be  employed. 

Hypodermoclysis  with  normal  saline  solution,  .ovj  (375  cc.)  to 
Oj  (500  cc),  given  at  105°  V.,  through  a  large  needle  attached  to  a 
fountain  syringe,  preferably  between  the  iliac  crest  and  twelfth  rib, 
is  valuable  and  does  not  stimulate  too  rapidly. 

15 


226  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

In  emergency  I   saved  one  patient  by  employing  an  ordinary 

hypodermic  needle  and  elevating  the  fountain  syringe  6  to  8  feet 

to  obtain  forcible  flow.     In  this  event  a  higher  temperature  (i  i8°  F.) 

should  be  employed,  as  the  fluid  cools  in  passing  through  the  small 

.  needle. 

In  one  case,  having  no  time  to  perform  infusion,  I  needled  a  large 
superficial  vein  with  a  hypodermic  needle^  and  infused  by  this  method. 
Infusion  with  i  liter  normal  saline  solution  at  120°  F.  in  severe 
cases  is  indicated.  Direct  infusion  of  blood  from  donor  to  patient 
is  generally  impractical  and  the  simple  method  is  the  best. 

Strychnin,  gr.  V^  to  3V  (0.00108-0.002 1),  every  three  or  four 
hours  by  hypodermic  or  camphor,  pulv.,  gr.  v  (0.3),  in  sterile  almond 
oil,  ITlxx  (1.184  cc). 

A  single  dose  by  hypodermic  and  repeated  in  three  or  four  hours, 
if  necessary.  Bandaging  the  extremities  and  elevation  of  the  foot 
of  the  bed  are  of  service. 

Whisky  or  brandy,  o  j  to  ij  (30.0-60.0),  may  be  added  to  the  enema. 

The  rational  methods  for  the  cure  of  acute  or  chronic  gastric 
ulcer  differ  widely,  the  chief  exponents  being  Leube-Ziemssen  and 
Lenhartz. 

General  Principles. — ^There  are  certain  general  principles  to  which 
I  must  first  refer. 

Absolute  rest  in  bed  for  a  period  of  two  to  four  weeks,  even  though 
the  hemorrhage  may  not  have  taken  place  recently,  gives  the  best 
results. 

Cruveilhier  first  recommended  milk  in  gastric  ulcer  as  an  ideal 
food.  Pure  milk  coagulates  rapidly  with  some  patients  and  does 
not  agree.  Boiled  milk  does  not  form  large  curds  and  leaves  the 
stomach  more  rapidly.  Ivime-water  or  milk  of  magnesia  lessens 
milk  coagulability. 

lycnhartz  believes  that  the  general  nutrition  should  be  improved 
as  rapidly  as  possible  to  hasten  the  healing  of  the  ulcer,  and  that 
sufficient  milk  to  secure  this  result  requires  so  large  a  quantity  that 
it  would  overdistend  the  stomach.  Though  given  in  divided  doses, 
he  states  that  2  to  3  quarts  per  diem  are  excessive,  and  limits  the 
total  quantity  of  milk  to  i  liter,  adding  other  materials  to  increase 
the  calorie  value. 

Riegel  demonstrated  the  capacity  of  egg-albumen  to  bind  free 
hydrochloric  acid,  and  also  the  use  of  sugar  solutions  to  lessen  acid 
secretion,  such  as  pure  dextrose  or  even  ordinary  dextrose.  These 
possess  high  calorie  value. 

Soluble  dry  peptonoids — oj  (30.0) — have  a  calorie  value  of  120.4. 
They  dissolve  in  milk  or  water.  Milk  powder  (gm,  100) ;  Gartner's  fat 
milk;  casein  nutrose,  gm.  30  to  60;  somatose,  oiv  to  vj  (16.0-24.0),  and 
notably  sanatogen,  20  to  30  gm.  per  diem,  possess  nutritive  qualities. 

Among  other  foods  are  meat  jelly,  prepared  by  boiling  chicken 
^Manual  on  Enteroclysis,  Hypodermoclysis,  r.nd  Infusion  (Kemp). 


ULCER   OF   THE    STOMACH  227 

or  beef  with  calves'  feet  (Fleming),  Leube-Rosenthal's  meat  solution; 
flour  soup  boiled  with  milk;  and  barley-water  or  rice-water  to  dilute 
the  milk. 

Protection  of  the  gastric  mucosa  and  lessening  hyperchlorhydria 
by  the  use  of  olive  oil — oss  to  j  (16.0-32.0) — t.  i.  d.  before  meals  is 
of  service. 

Kaufmann^  has  demonstrated  that  the  normal  gastric  piucus 
exercises  a  protective  influence  and  is  absent  in  ulcer,  and  that  silver 
nitrate  both  aids  the  healing  of  ulcer  and  stimulates  mucous  secre- 
tion. Turck  substantiates  this  by  showing  the  increase  of  mycogen 
cells  during  the  process  of  healing. 

Large  doses  of  bismuth  act  as  a  protective  layer  to  the  ulcer  and 
prevent  irritation. 

Neutralization  of  the  free  hydrochloric  acid  is  important.  Among 
the  most  valuable  alkalis  are  magnesia  usta,  milk  of  magnesia 
(Phillips),  and  soda  bicarbonate.  Magnesia  preparations  are  also  of 
use  for  the  constipation.  If  their  action  becomes  excessive,  bismuth 
can  be  combined. 

At  times  I  employ  soda  bicarbonate  in  combination  with  magnesia. 
Bicarbonate  alone  is  apt  to  produce  too  much  carbonic  acid  gas  and 
distend  the  stomach. 

In  cases  without  dilatation,  Carlsbad  water  or  the  salts  are  of 
service,  as  they  lessen  gastric  secretion  and  empty  the  bowels.  They 
form  a  permanent  feature  in  Leube's  cure. 

Belladonna  is  valuable  when  there  is  hypersecretion,  gr.  -^  (0.022) 
of  the  extract  or  TTLio  (0.6)  of  the  tincture  three  times  a  day. 

Iron  and  arsenic  are  imperative  to  improve  the  condition  of  the 
blood.  Alcoholic  drinks,  coffee  and  tobacco,  heavy  salads,  hot 
breads,  acids,  pastry,  etc.,  should  be  excluded  during  the  course  of 
treatment. 

If  nutritive  enemata  are  given  for  twenty-four  hours  following 
Leube's  method,  plain  milk  should  never  be  emploved,  but  should 
always  be  peptonized.  This  feature  is  often  overlooked.  An  enema 
of  saline  solution  should  be  administered  an  hour  or  more  before  the 
nutritive  enema  in  order  to  cleanse  the  bowel.  The  following  is  of 
service:  Peptonized  milk,  125  cc.  (oiv) ;  raw  egg,  or  whites  of  2  eggs 
beaten  up;  salt,  i.oo  (gr.  15) ;  sanatogen,  8.0  (5ij) ;  water,  q.  s.  250  cc. 
(oviij). 

Somatose,  5ij  (8.0),  or  dry  peptonoids,  5j  (4-0),  or  liquid  pepto- 
noids,  oj  (32.0),  may  be  substituted  for  sanatogen.  Four  nutritive 
enemata  should  be  given  during  the  day  of  sixteen  hours. 

Metzger  has  shown  that  wine  in  the  enema  increases  gastric 
secretion. 

Having  enunciated  the  general  principles  of  treatment,  I  will 
describe  the  chief  meAods  employed  and  the  procedures  with  which 
I  have  been  most  successful  in  my  own  experience. 

^  American  Journal  of  the  Medical  Sciences,  Feb.,  1908. 


228  DISEASES   OF   THE)    STOMACH   AND   INTESTINES 

Riegel  confines  himself  exclusively  to  rectal  feeding  for  six  or 
eight  days  at  the  commencement  of  treatment  following  hematemesis, 
giving  only  a  few  pieces  of  ice  by  mouth,  and  then  follows  with  a 
mild,  non-irritating  diet  and  the  use  of  Carlsbad  water  or  salts;  while 
others  confine  the  feeding  to  the  rectum  for  two  to  three  weeks. 

Good  results  have  been  reported,  but  as  the  patient  is  suffering 
from  subnutrition,  these  methods  can  be  improved  upon. 

Leube-Ziemssen  Rest  Cure. — This  is  substantially  as  follows: 
The  patient  is  kept  in  bed  for  two  to  three  weeks,  not  being  allowed 
to  rise  for  any  purpose,  either  for  defecation  or  urination;  rectal 
feeding  for  several  days  if  hematemesis  has  just  occurred ;  hot  poultices 
(flaxseed)  over  the  stomach  by  day  and  warm  Priessnitz  compresses 
at  night.  Then  after  the  first  two  to  three  days  the  subsequent  diet 
for  ten  days  should  consist  chiefly  of  milk,  or  milk  with  barley-water, 
strained  barley,  oatmeal-  or  rice-water,  tea  and  a  little  bouillon. 
For  the  next  ten  days  boiled  calves'  brain,  boiled  thymus,  rice  and 
sago  in  milk,  gruels  and  mushes,  raw  and  soft-boiled  eggs.  This  is 
followed  by  a  little  scraped  rare  or  raw  beef.  Scraped  raw  ham  and 
mashed  potato  for  a  week  or  so  are  added,  and  finally  broiled  chicken, 
venison  or  roast  beef,  pike  and  shad,  etc. ;  coarse  bread,  skin,  tendons, 
fruits,  alcohol,  and  acids  should  be  avoided. 

Carlsbad  water,  a  glass,  or  5j  to  ij  (4.0-8.0)  Carlsbad  salts  in  Bviij 
(250  cc.)  of  water  should  be  taken  half  an  hour  before  breakfast. 
This  can  be  begun  after  the  first  week  or  ten  days. 

Einhorn  ^  employs  nutritive  enemata  for  a  day  or  so  after  hema- 
temesis, and  then  milk  as  the  basis  of  his  diet  for  the  first  two  weeks; 
for  the  first  week  giving  5v  (150  cc.)  every  hour,  adding  barley-water 
and  bouillon;  and  gradually  increasing  the  quantities  of  milk,  but 
giving  it  at  longer  periods,  adding  eggs,  crackers,  etc.,  at  the  end  of 
ten  days,  gradually  increasing  the  diet. 

Lenhariz's  Method. — Lenhartz^  believes  that  many  cases  of  gas- 
tric ulcer  do  not  definitely  improve,  or  but  very  slowly,  under  the 
method  of  entrenched  milk  feeding;  that  the  high  acidity  is  not 
measurably  lessened ;  and  that  if  patients  are  in  a  poor  physical 
condition  consequent  upon  one  or  more  hemorrhages,  often,  indeed, 
in  collapse,  the  "starvation  treatment" — the  ice  and  nutrient 
enemata  and  insufficient  milk  feeding  following — not  only  maintain 
the  patient  in  his  anemic  state,  but  may  even  drag  him  into  serious 
inanition,  and  such  an  undermined  constitution  hardly  favors  the 
speedy  healing  of  an  ulcer.  Frequent  nutrient  enemata  excite  the 
gastro-intestinal  tract  into  peristaltic  activity  and  may  thus  induce 
renewed  bleeding ;  besides,  very  little  nutriment  is,  after  all,  obtainable. 

Should  more  milk  be  given  by  mouth,  merely  enough  to  preserve 
the  body  weight — 3  liters  for  an  adult — would  overfill  the  stomach 

^  New  York  Medical  Journal,  Nov.  20,  1909.  This  author  now  employs  raw 
eggs  and  milk  from  the  first  day.  ■ 

2  International  Congress  at  Wiesbaden,  1901;  Therapeutic  Gazette,  Nov.  16, 
1906. 


ULCER   OP  THE   STOMACH 


229 


and  stretch  its  walls,  thus  pre- 
venting a  contraction  of  the  ulcer 
and  again  offering  the  danger  of 
renewed  bleeding.  He  advises 
another  dietary  treatment,  one 
that  will  especially  combat  the 
hyperchlorhydria  and  reinforce 
the  enfeebled  and  anemic  state 
of  the  patient. 

The  concentrated  egg-albumen 
diet  was  tried.  In  case  after  case 
the  effect  proved  so  gratifying 
that  this  method  became  the 
routine  treatment.  The  sour 
regurgitation  subsides,  the  vomit- 
ing immediately  ceases,  the  pain 
and  distress  after  eating,  within 
a  few  hours  to  a  few  days,  dis- 
appear, and  finally  an  increase 
in  the  body  weight  is  manifest 
as  early  as  the  first  week.  Be- 
sides, the  improvement  is  com- 
paratively rapid,  so  that  the 
patient  can  be  dismissed  as 
cured  within  a  briefer  time  than 
formerly. 

The  following  is  the  tabu- 
lated regimen:  "Absolute  rest  in 
bed  for  at  least  four  weeks.  All 
mental  excitement  to  be  avoided. 
An  ice-bag  is  placed  upon  the 
stomach  and  kept  there  almost 
continually  for  two  weeks.  This 
prevents  gaseous  distention  and 
promotes  contraction  of  the 
stomach  walls,  thus  tending  to 
obviate  hemorrhage,  and  eases  the 
pain  when  present.  On  the  first 
day,  even  when  a  hematemesis 
has  occurred,  the  patient  receives 
between  200  and  300  cc.  (ovj-ix) 
of  iced  milk  given  in  spoonfuls 
and  from  2  to  4  beaten  raw  eggs 
within  the  first  twenty-four  hours. 
At  the  same  time  bismuth  sub- 
nitrate  is  given  twice  or  thrice  a 
day,  2  grams  (gr.  30)  per  dose,  and 


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230  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

continued  for  ten  days.  The  eggs  are  beaten  up  entire  (with  a  Httle 
sugar),  and  the  cup  containing  them  is  placed  in  a  dish  filled  with 
ice,  so  that  they  remain  cold.  This  food  at  once  'binds'  the  super- 
secreted  acid  and  therefore  mitigates  the  pain  rapidly,  and  causes 
the  vomiting,  often  quite  troublesome,  to  cease.  The  portion  of  milk 
is  increased  daily  per  100  cc.  (oiij),  and  at  the  same  time  i  additional 
egg  is  given,  so  that  at  the  end  of  the  first  week  the  patient  is  receiving 
800  cc.  (oxxv)  of  milk  and  from  6  to  8  eggs.  Both  these  foods  are  now 
continued  in  the  same  amount  pro  die  for  another  week.  No  more 
than  /  liter  of  viilk  a  day  is  allowed  at  any  time.  Besides  milk  and 
eggs,  some  raw  chopped  meat  is  given  from  the  fourth  to  the  eighth 
day,  usually  on  the  sixth,  35  grams  (Six)  pro  die,  in  small  divided 
doses  (stirred  up  with  the  eggs  or  given  alone) ;  the  day  after  70 
grams  (oxviij),  and  later  possibly  more  if  well  digested.  The  patient 
is  now  able  to  take  some  rice,  well  cooked,  and  a  few  zwieback  (soft- 
ened). In  the  third  week  quite  a  mixed  diet  is  tolerated,  the  meat 
being  given  now  well  cooked  or  lightly  broiled." 

All  heavy  foods  are  interdicted,  as  well  as  vegetables  with  husks, 
etc.,  and  those  tending  to  produce  flatulence.  The  patient  is  given 
strict  orders  to  masticate  his  food  thoroughly.  The  table  on  page 
229  gives  the  daily  quantities. 

The  bowels  are  not  moved,  both  in  order  to  avoid  any  peristaltic 
irritation  and  to  permit  the  reabsorption  of  blood  that  may  have 
passed  into  the  intestine.  One  need  pay  absolutely  no  attention  to 
constipation  in  the  first  week,  even  in  many  cases  to  the  end  of  the 
second.  After  the  second  week  the  bowels  are  moved  with  small 
glycerin  injections  or  warm  water,  and  after  the  third  week  this  is 
done  daily  if  a  movement  does  not  occur  spontaneously.  After  this 
one  tries  to  control  the  bow^els  b}^  means  of  the  food  and  by  getting 
the  patient  to  go  to  stool  regularly. 

For  the  anemia  iron  is  given  in  the  form  of  a  soft  preparation  of 
Blaud's  pills: 

'B/,.     Ferri  sulphas lo.o  gm. 

Magnesia  usta 1.75  gm. 

Glycerinum, gtt.  xxx  (3.6  gm.). — M. 

Divide  in  pilulse  Ix;  2  pills  to  be  taken  Uxo  or  three  times  a  day. 

The  pills  are  given  as  early  as  the  sixth,  eighth,  or  tenth  day  of 
treatment,  according  to  need,  administering  them  first  in  a  macerated 
condition. 

In  severe  cases  arsenic  is  also  given  in  the  form  of  "Asiatic  pills, " 
each  containing  0.000 1  gm.  of  arsenous  acid.  The  dose  is  gradually 
increased,  3  for  three  days,  4  for  four  days,  up  to  7  for  seven  days, 
then  decreasing  again,  6  for  six  days,  etc.  After  the  tenth  day  and 
to  the  sixth  week  bismuth  compositum  is  substituted  for  the  subni- 
trate  and  given  three  times  a  day  before  meals.  The  patient  is 


ULCER    OF    THE    STOMACH  23 1 

usually  allowed  up  on  the  twenty-eighth  day  and  is  dismissed  in  the 
sixth  to  the  tenth  week.  Lenhartz  reports  only  8  per  cent,  of  recur- 
rent hemorrhages  after  this  method  of  treatment  as  compared  with 
20  per  cent,  after  the  older  methods.  No  unfavorable  results  were 
produced. 

Samuel  Lambert,  of  New  York,  has  reported  favorable  results. 

Senator's  Method. — Senator  has  modified  Lenhartz's  treatment 
and  employs  a  nourishing  diet,  non-irritating,  which  tends  to  check 
hemorrhage.  It  consists  chiefly  at  first  of  gelatin,  fat,  and  sugar. 
At  first  a  10  per  cent,  sweetened  gelatin  solution  is  given  in  table- 
spoonful  doses  every  fifteen  minutes  to  two  hours.  Small  amounts 
of  fresh  butter  and  cream  are  allowed,  the  butter  given  in  small 
frozen  balls  and  the  cream  beaten  up  with  sugar  to  form  whipped 
cream.  The  daily  allowance  is  from  900  to  1000  calories  and  mav  be 
begun  im.mediately  after  a  hemorrhage.  Gelatin  is  later  replaced 
by  calves'-foot  jelly,  etc.  He  occasionally  adds  rectal  feeding, 
though  little  of  late.     Gradual  additions  are  made  to  the  diet. 

Schmidt^  believes  in  the  Lenhartz  principle  of  feeding,  but  does 
not  increase  the  diet  as  rapidly.  He  gives  the  stomach  rest  a  few 
days,  like  Leube,  and  then  increases  the  diet  more  rapidlv  bv  giving 
gelatin,  eggs,  butter,  cream,  sugar,  and  rice;  but  chopped  meat  and 
ham  with  caution. 

]\Iy  own  method  depends  upon  whether  I  first  treat  the  patient 
during  the  period  of  hemorrhage  or  later. 

If  the  hemorrhage  is  taking  place  or  has  just  occurred,  5j  to  ij 
(4.0-8.0)  of  a  5  to  10  per  cent,  solution  of  sweetened  gelatin  is  given 
cold  every  half  hour  for  ten  to  twelve  hours,  even  if  there  be  vomiting. 
During  the  remaining  period  of  the  first  twenty-four  hours  the  gelatin 
is  continued,  5ss  to  j  (16.0-32.0),  every  two  to  three  hours  while 
the  patient  is  awake,  and  in  addition  the  whites  of  2  raw  eggs  are 
beaten  up  and  placed  in  a  cup  on  ice  and  given  in  divided  doses. 
An  ice-bag  is  kept  on  for  at  least  two  weeks  if  hemorrhage  has  just 
occurred. 

Gelatin  treatment  is  continued  for  a  week.  Scraped  beef  and  ham 
are- omitted  for  the  first  two  weeks  and  cream  substituted,  to  obtain 
the  calorie  values.  A  little  sugar  can  be  beaten  up  with  the 
cream. 

The  day  following  the  hemorrhage  milk  is  begun,  200  cc.  (ovj) 
cold,  in  spoonful  doses,  100  gm  (10  per  cent,  gelatin  solution)  cold,  in 
divided  doses — oss  (16.0) — every  three  hours,  and  i  raw  egg  beaten 
up  and  given  in  divided  doses.  These  are  placed  in  cups  which  are 
packed  in  ice.  The  milk  is  increased  100  cc.  daily  up  to  1000  cc, 
and  no  more ;  eggs  are  increased  daily  i  egg  up  to  8  a  day.  Sana- 
togen,  preferably  flavored,  is  begun  on  the  third  day  (second  day  after 
hemorrhage).  With  the  exceptions  noted,  the  rest  of  the  diet  is  after 
Lenhartz. 

1  Deutsch.  med.  Woch.,  Jan.  18,  igo6. 


232 


DISEASES    OF   THE   STOMACH   AND   INTESTINES 


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ULCER   OF   THE   STOMACH  233 

If  no  recent  hemorrhage,  I  start  the  diet  after  the  method  cor- 
responding to  the  third  day  in  the  table  on  page  232.  An  ice-bag  is 
kept  on  for  two  weeks  if  there  is  hemorrhage  or  one  within  a  week 
or  ten  days. 

Bismuth  subnitrate,  2.0  to  4.0  (5ss-j),  is  given  in  oij  (60.0) 
water  t.  i.  d.  before  feedings,  commencing  on  the  second  day  after 
hemorrhage.  At  times  I  combine  magnesia  usta,  i.o  (gr.  15),  or 
sod.  bicarb.,  i.o  (gr.  15),  with  the  bismuth. 

Tr.  belladonna,  TTLx  (0.66)  in  a  teaspoonful  of  water  can  be  given 
t.  i.  d.  for  pain.  I  prefer  to  move  the  bowels  gently  by  a  small 
soapsuds  enema  containing  oij  (60.0)  of  oHve  oil  on  the  third  day 
after  hemorrhage,  and  thereafter  every  other  day.  If  no  hemorrhage 
has  occurred  recently,  then  a  daily  movement  should  be  secured. 
Milk  of  magnesia,  5j  to  ij  (4.0-8.0)  in  oiv  (125.0)  water  given  on 
rising,  or  small  doses  of  Sprudel  salts,  5j  (4.0)  in  a  glass  of  hot  water, 
are  of  service. 

On  the  seventh  day  after  hemorrhage,  or  immediately  if  no 
hemorrhage,  iron  and  arsenic  should  be  given: 

1^.     Blaud's  iron  pill gf-  v  (0.3)  (made  fresh) 

Sod.  arsen gr-  3*0  (0.0013) 

Pill  made  soft  with  honey  and  crumbled  when  taking,  one  pill  t.  i.  d.  after 
eating.     The  arsenic  can  be  gradually  increased  to  gr.  2V  (0.0026)  sod.  arsen.  t.  i.  d. 

I  give  no  scraped  beef  until  the  commencement  of  third  week 
after  hemorrhage,  and  then  increase  the  diet  after  Leube's  method. 
The  bismuth  treatment  should  be  continued,  or  one  can  substitute 
the  nitrate  of  silver  treatment.  It  is  advisable  to  keep  this  up  for 
several  months  as  a  precaution,  and  then  continue  the  diet  and  alka- 
line treatment  for  hyperchlorhydria  for  a  considerable  period. 

At  the  end  of  three  weeks  the  patient  may  be  allowed  to  sit  up 
for  a  short  time  daily;  and  at  the  end  of  four  weeks  to  begin  to  go 
outdoors  for  a  short  time.  In  favorable  cases  it  is  advisable  not  to 
resume  work  under  six  weeks.  Some  of  the  chronic  cases  either  will 
not  remain  in  bed  or  cannot,  for  financial  reasons. 

In  such  event  we  are  obliged  to  employ  careful,  but  liberal  feed- 
ing; the  use  of  Carlsbad  salts,  iron  and  arsenic  tonics,  and  either  the 
subnitrate  of  bismuth  treatment  with  an  alkali  in  addition,  or 
nitrate  of  silver.     The  following  prescriptions  are  of  service : 

I^.     Bismuth  subnitrate,  2.0  to  4.0  (oss-j), 
suspended  in  4  ounces  (125  cc.)  of  water,  and  given  t,  i.  d.  half  an  hour  before 
meals. 

This  is  preferable   to   pouring  the  bismuth  suspension   through  a 
stomach-tube. 

As  olive  oil  protects  the  surface  and  lessens  the  secretion,  I 
sometimes  employ  the  bismuth  suspended  in  oj  to  ij  (30.0-60.0)  of 
olive  oil  instead  of  water.     Alkalis  should  also  be  used. 


234  DISEASES    OF"   THE   STOMACH   AND   INTESTINES 

I^.     Magnesia  usta 2.0  (gr.  30),  or 

Milk  of  magnesia 4.0  to  8.0  (3i-ij) 

In  3  or  4  ounces  (100-125  cc.)  of  water  alone,  or  combined  with  equal  quantities 
of  soda  bicarbonate. 

T^.     Soda  bicarb., 

Magnesia  usta aa  lo.o  (5iiss) 

Milk-sugar 2.0  (3  ss) 

Dose,  2.0  (5ss)  in  water  t.  i.  d.  an  hour  after  eating. 

Nitrate  of  silver  can  be  employed  in  place  of  the  bismuth,  to  be 
given  on  an  empty  stomach  t.  i.  d.  half  an  hour  before  meals,  as 
advocated  by  Boas  and  Kaufmann: 

^.     Argenti  nitratis 0.2  (gr.  3) 

Aq.  destil 180.0  (ovj) 

Keep  in  dark  bottle.  Tablespoonful  in  wineglass  of  water  t.  i.  d.  half  an 
hour  before  eating. 

Occasionally  lavage  of  stomach  v/ith  i :  5000  to  i :  3000  silver 
nitrate  has  been  advocated  once  or  twice  a  week,  if  there  has  not 
been  a  hemorrhage  for  some  weeks;  but  the  internal  administration 
is  safer.  It  should  be  given  for  two  to  three  weeks,  then  discon- 
tinued and  the  bismuth  substituted. 

The  alkali  can  be  given  in  addition  t.  i.  d.  an  hour  after  meals. 
The  meals  should  preferably  be  frequent  and  in  smaller  quantities, 
as  in  hyperchlorhydria. 

Tincture  of  belladonna,  TTLx  (0.66) ;  or  extract  of  belladonna,  gr.  \ 
(0.022);  or  atropin,  gr.  yg-Q  (.0006),  may  be  given  t.  i.  d.  for  pain 
or  excessive  secretion.     It  is  a  valuable  remedy  and  lessens  HCl. 

Rarely  a  hypodermic  of  gr.  \  to  \  (0.016-0.032)  of  codein  or 
morphin,  gr.  i  to  ^  (0.008-0.0016),  may  be  necessary  for  acute  pain. 

In  cases  complicated  by  stenosis  and  ectasia  lavage  is  necessary 
for  the  fermentation,  and  olive  oil  oj  to  ij  (30.0-60.0)  t.  i.  d.  before 
the  chief  meals,  to  aid  the  passage  of  food.  The  application  of 
Rose's  belt,  and  the  patient  lying  on  the  right  side  for  half  an  hour 
after  eating,  both  temporarily  aid  in  emptying  the  stomach. 
.  Hemorrhage  is  rare  in  this  type,  the  ulcer  being  dormant  and  the 
chief  symptoms  due  to  stenosis.  Surgery,  gastro-enterostomy  espe- 
cially, is  advocated  in  these  cases.  If  tetany,  the  same  procedure  is 
advisable. 

Vomiting. — In  cases  described  by  Lenhartz,  this  is  relieved  by 
neutralizing  the  acid,  and  this  is  the  best  treatment.  Rarel}^  rectal 
feeding  may  be  required  for  a  few  days.  Bismuth  subnitrate,  gr.  2 
(0.13),  and  oxalate  of  cerium,  gr.  i  (0.065),  should  be  given,  or  i-drop 
doses  of  Fowler's  solution  of  arsenic,  four  in  all,  an  hour  apart.  If 
the  vomiting  continue,  a  single  cautious  lavage  is  a  safer  procedure 
than  the  risk  of  recurrent  hemorrhage  from  the  strain  of  emesis. 

Pain. — Rose's  belt  will  at  times  aid  in  alleviating  the  pain  due 
to  the  dragging  of  adhesions,  by  the  support  afforded  to  the  viscera. 

Perforation. — Temporarily,     rectal    feeding,     a    hypodermic    of 


BXULCERATIO   SIMPLEX  235 

morphin,  the  ice-bag,  and  cautious  lavage  after  cocainizing  the 
pharynx,  as  suggested  by  Ewald.  Immediate  recourse  should  he  had 
to  laparotomy. 

Surgery. — The  following  are  the  indications  for  operation: 
Perforation  with  commencing  peritonitis;  local  peritonitis,  with  or 
without  abscess;  subphrenic  abscess;  perigastric  adhesions;  ectasia 
due  to  stenosis  from  ulcer  or  spasm  from  its  irritation;  gastric  tetany 
with  ulcer. 

In  recurring  acute  hemorrhages  the  Mayos  advise  opening  the 
stomach,  locating  the  bleeding  point,  suturing  it  firmly  with  catgut 
on  the  inner  (mucous)  side,  and  protecting  the  region  by  mattress 
sutures  (musculoperitoneal).  Gastrojejunostomy  they  have  not 
found  reliable. 

In  6  cases — i  case  of  death  from  hemorrhage  followed  gastro- 
jejunostomy— 5  cases  treated  by  primary  operation  on  the  bleeding 
point,  with  or  without  excision  of  the  ulcer,  recovered.^ 

In  cases  of  chronic  ulcer,  with  recurrent  hemorrhages,  after 
systematic  treatment  for  eight  months  to  a  year  by  the  methods 
I  have  described,  and  if  the  patient  is  still  losing  ground,  I  advocate 
resort  to  surgery.  I  am  av/are  that  some  surgeons  are  loth  to  operate 
on  such  cases  unless  there  is  pyloric  stenosis,  and  claim  that  in  such 
event  the  gastric  contents  will  not  pass  through  the  new  opening, 
but  through  the  pylorus.  Cannon  and  Blake  have  demonstrated 
this  experimentally  on  animals.  On  the  other  hand,  when  a  large 
anastomotic  opening  is  made,  this  has  been  shown  to  be  of  practical 
value,  especially  by  the  posterior  no-loop  method. 

It  has  been  demonstrated  that  the  pancreatic  juice  and  bile 
entering  the  stomach  aid  in  neutralizing  the  hyperacidity,  and  this 
is  of  service. 

Wm.  Mayo  states  that  in  chronic  ulcer,  where  there  is  no  mechanic 
obstruction,  the  result  has  not  been  as  favorable.  Unfortunately, 
we  do  find  cases  of  multiple  ulcers  with  hemorrhages  from  various 
areas  and  with  an  open  and  soft  pylorus,  such  as  Munro^  reports, 
in  which  the  results  of  surgery  are  not  favorable;  but  in  any  event 
the  lessening  of  hyperacidity  through  gastro-enterostomy  is  of  value. 

In  cases  of  pyloric  obstruction  (stenosis)  from  ulcer  with  dilatation 
of  the  stomach,  I  always  advocate  surgical  procedure,  finding  that 
though  there  may  be  temporary  improvement  at  times  quite  marked 
under  medical  treatment,  in  every  case  there  is  subsequent  relapse. 

EXULCERATIO  SIMPLEX   (DIEULAFOY)   OR   SUPERFICIAL  ULCER- 
ATION OF  THE  STOMACH 

Small  ulcerations  of  the  mucous  membrane  of  the  stomach,  so 
minute  that  they  appear  to  be  little  more  than  erosions,  have  been 
observed,  from  which  fatal  hemorrhage  has  taken  place. 

1  Journal  Amer.  Med.  Association,  Sept.  22,  1906. 

2  Annals  of  Surgery,  June,  1907. 


236  DISEASES    OF    THE   STOMACH   AND   INTESTINES 

The  usual  symptoms  of  ulcer  have  been  absent  and  no  vomiting 
occurred  prior  to  the  hemorrhage. 

Dieulafoy  was  the  first  to  minutely  describe  this  affection. 

Anatomy. — There  is  a  superficial  round  or  elliptic  loss  of  sub 
stance,  involving  merely  the  mucous  membrane  and  the  muscularib 
mucosae  and  some  blood-vessels.  It  does  not  penetrate  further 
into  the  coats  of  the  organ.  The  defect  may  be  from  pinhead  size 
to  a  quarter  of  a  dollar  in  dimension ;  the  margins  are  not  indurated, 
and  it  may  be  difficult  to  detect  even  on  autopsy,  being  concealed  in 
some  of  the  folds  of  the  mucous  membrane.  The  stomach  is  healthy 
throughout.  There  may  be  a  slightly  reddened  zone  about  the  area 
and  it  may  be  in  any  location. 

Etiology  is  unknown.  It  may  be  the  beginning  of  an  ordinary 
ulcer,  or  possibly  a  toxic  element  is  responsible. 

Age. — Chiefly  in  persons  from  twenty-five  to  thirt3^ 

Symptoms. — The  patient  is  in  perfect  health,  when  he  suddenly 
vomits  0.1  {h  liter)  to  i  quart  (liter)  of  blood,  accompanied  by 
melena.  The  hemorrhage  may  prove  fatal.  The  symptoms  are 
those  of  any  hemorrhage:  dizziness,  cold  extremities,  collapse,  and 
the  patient  may  become  rapidly  moribund.  Occasionally  the  patient 
may  recover  and  suffer  from  recurrences. 

Diagnosis. — Ordinary  cases  of  gastric  ulcer  suffer  from  gastric 
symptoms,  while  these  cases  do  not. 

From  latent  ulcer  of  the  stomach  it  cannot  be  differentiated. 

In  chronic  erosions  there  are  no  hemorrhages. 

Treatment. — This  is  the  same  as  in  hematemesis  from  ulcer, 
morphin,  gr.  \  (0.016);  ice-bag  over  stomach;  10  per  cent,  gelatin 
solution  every  half  hour  oij  (8.0)  by  mouth;  lactate  of  calcium, 
gr.  X  (0.66),  by  mouth  and  by  rectum;  ergot  injections,  hypoder- 
moclysis  (2  per  cent,  gelatin),  also  of  saline  solution,  etc. 

Dieulafoy  recommends  operative  procedure,  suturing  the  bleeding 
point,  if  medical  remedies  fail  or  if  the  hemorrhages  are  recurrent. 

GASTRIC  EROSIONS 
These  are  subdivided  into  acute  erosions  and  chronic  erosions. 

Acute  Erosions  (Hemorrhagic  Erosions) 

These  are  small  (2  to  4  mm.)  abrasions  of  the  mucosa  of  the 
stomach,  in  character  usually  multiple,  and  extend  partly  or  through 
the  layer.      There  is  hemorrhage  (hematemesis)  with  this  type. 

The}^  occur  in  the  newborn ;  in  the  cachexia  of  children ;  in  chronic 
heart  and  arterial  diseases ;  cirrhosis  of  the  liver ;  in  acute  infections 
with  the  pneumococcus  (Dieulafoy);  and  with  septic  organisms; 
also  in  postoperative  cases,  and  associated  with  the  throbbing  aorta 
in  a  considerable  number  of  neurotic  women. 

Treatment  is  of  hematemesis  and  also  of  the  cause. 


gastric  erosions  237 

Chronic  Erosions  (Erosions  of  the  Stomach) 

An  erosion  is  a  small  superficial  exfoliation  of  the  gastric  mucous 
membrane.  Erosions  of  the  stomach  have  been  quite  frequently 
found  at  autopsy,  and  the  subject  has  been  discussed  by  Virchow, 
Ewald,  Gerhart,  and  others.     The  latter  found  nothing  characteristic. 

Riegel  notes  the  frequency  with  which  small  fragments  of  mucous 
membrane  are  washed  out  of  the  stomach,  and  believes  it  due  to  the 
tearing  from  this  procedure.  He  denies  its  significance  as  a  special 
pathologic  process,  but  believes  that  at  times  an  examination  of  the 
fragments  will  demonstrate  the  general  condition  of  the  mucous 
membrane. 

There  is  even  to-day  some  dispute  as  to  whether  the  erosions  of 
the  stomach  can  be  described  as  a  separate  clinical  entity,  in  view  of 
the  fact  that  in  the  majority  of  cases  there  is  a  chronic  gastritis,  and 
only  on  lavage  the  bits  of  mucous  membrane  are  secured,  some 
believing  it  to  be  due  to  manipulation  with  the  tube. 

We  must  credit  Einhorn^  with  first  describing  erosions  of  the 
stomach  as  a  clinical  entity.  Pariser,^  Quintard,^  Mintz,*  and  others 
have  described  cases. 

Undoubtedly,  not  in  every  case  in  which  bits  of  mucous  membrane 
are  washed  out  of  the  fasting  stomach  have  we  chronic  erosions. 
I  have  noted  in  several  cases  of  chronic  gastritis — in  which  unques- 
tionably lavage  was  performed  in  an  unscientific  manner  by  the 
physician  in  attendance — the  appearance  of  these  small  fragments, 
and  yet  the  patient  never  subsequently  suffered  from  the  salient 
symptoms  described.     Traumatism  was  the  evident  cause. 

Erosions  may  occur  in  acute  cases.  I  was  recently  called  to  attend 
a  patient  with  acute  gastritis,  having  severe  and  persistent  vomiting 
streaked  with  blood,  and  though  I  washed  the  stomach  with  greatest 
care,  in  two  washings  several  pieces  of  gastric  mucous  membrane 
were  found,  evidently  exfoliation  from  the  acute  process  and  violent 
vomiting.  The  case  made  a  rapid  recovery  with  no  further  symp- 
toms. 

Unrecognized  cases  of  chronic  erosions  occur,  but  those  recog- 
nized intravitam  by  the  clinical  symptoms  are,  so  far  reported,  com- 
paratively few. 

Etiology. — Chronic  catarrhal  gastritis  is  the  chief  factor,  though 
Einhorn  reports  erosions  associated  with  hyperchlorhydria,  and 
I  have  seen  them  once  with  acid  gastritis. 

Symptoms. — The  diagnostic  symptoms  described  by  Einhorn  are: 

Pain,  emaciation,  weakness  and  lassitude,  and  the  finding  in  the 
wash-water  after  lavage  of  one  or  more  small  pieces  of  gastric  mucous 

1  New  York  Med.  Record,  June  23,  1894;  also  Journal  Am.  Med.  Asso.,  May  20, 
1894. 

2  Berlin  klin.  Wochenschr.,  1900,  No.  43. 
^  Arch.  f.  Verdauungskrankheiten,  1901. 
*  Zeitschr.  f.  klin.  Med.,  Bd.  46,  1902. 


238  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

membrane.     There  is  usually  decrease  in  acidity  and  free  hydro- 
chloric acid  and  considerable  mucus  (chronic  gastritis). 

Pains. — These  are  not  intense  and  occur  directly  after  meals, 
irrespective  of  the  character  of  the  food.  They  last  one  or  two  hours 
and  are  never  severe.  There  are  usually  intervals  free  from  pain, 
though  rarely  the  pains  are  constant. 

Emaciation. — The  patients  lose  weight  at  first;  the  face  becomes 
rather  thin.  They  have  not  the  cachexia  of  cancer  nor  the  appear- 
ance of  suffering  as  in  ulcer. 

Weakness. — The  patient  feels  weak  and  unable  to  work,  and  likes 
keeping  quiet,  most  markedly  so  for  a  period  after  meals.  Loss  of 
appetite  is  present  in  some  cases. 

If  the  stomach  is  washed  out  in  the  fasting  condition  one  or  more 
small  pieces  of  gastric  mucous  membrane  are  found  in  the  wash- water. 
They  appear  normal  under  the  microscope,  but  are  infiltrated  with 
red  blood-cells.     This  lesion  is  constantly  found  after  lavage. 

Blood  is  rarely  present,  though  occasionally  the  wash-water  is 
slightly  streaked  with  it. 

Einhorn  believes  the  "erosions"  resulting  from  the  peeling  off 
of  the  mucous  membrane  are  responsible  for  the  pain  and  tenderness, 
and  that  it  has  not  yet  been  determined  whether  the  exfoliation 
recurs  at  the  same  place  after  healing  or  in  new  regions  of  the  stomach. 

Gastric  Analysis. — The  hydrochloric  acid  secretion  is,  as  a  rule, 
decreased  and  also  the  total  acidity.  Considerable  mucus  is  usually 
found.  Rarely,  hyperchlorhydria  is  present  and  in  one  case  I  found 
acid  gastritis. 

In  washing  the  fasting  stomach,  one  to  four  pieces  of  mucous 
membrane  (0.3  to  0.4  cm.)  are  found.  They  are  blood-red  and  under 
the  microscope  the  gastric  glands  and  red  corpuscles  are  visible. 

Prognosis. — The  disease  is  usually  of  long  duration,  with  at 
times  intervals  of  improvement. 

Treatment. — The  diet  depends  on  the  gastric  findings.  The 
treatment  is  the  same  as  for  chronic  gastritis,  acid  gastritis,  or  for 
hyperchlorhA'dria,  depending  on  the  case.  Hydrotherapy  and 
out-of-door  exercise  are  of  service. 

If  deficient  hydrochloric  acid,  nux,  comp.  tinct.  cinchona,  and 
condurango  are  indicated;  if  hyperacidity,  the  alkaUs,  such  as 
magnesia  or  sodium  bicarbonate. 

There  are  three  methods  of  local  treatment: 

1.  Bismuth  Treatment. — Lavage  every  other  day  with  milk  of 
magnesia  to  dissolve  mucus,  and  t.  i.  d.  gr.  ^5  to  30  (1.0-2.0)  bismuth 
subnitrate  before  meals. 

2.  Nitrate  of  Silver  Treatment. — This  is  superior  in  manv  cases. 
It  may  be  administered  internally,  gr.  \  (0.016)  in  solution  t.  i.  d. 
three  hours  after  eating;  lavage  with  an  alkali  every  two  or  three 
days  depends  on  the  mucus;  or  lavage  every  other  day  with  i  :  2000 
to  1 :  1000  silver  nitrate,  preceding  it  by  lavage  with  warm  water. 


•  GASTRIC    EROSIONS  239 

Einhorn  recommends  intragastric  galvanization  on  one  day,  with 
nitrate  of  silver  spray  preceded  by  lavage  on  the  following  day,  and 
so  alternating. 

He  first  washes  the  stomach  with  warm  water,  which  is  all 
removed,  and  then  sprays  the  stomach  with  his  instrument,  emploving 
10  cc.  of  a  0.1  to  0.2  per  cent,  solution  of  nitrate  of  silver  solution, 
employing  most  of  it  and  moving  the  tube  about.  The  bottle  should 
be  opened  before  removal  of  the  spray. 

3.  The  extract  of  the  suprarenal  gland  (iVrmour  and  Co.)  has  been 
recommended  by  Einhorn.  He  employs  it  in  his  powder-blower 
and  applies  it  every  other  day  to  the  stomach,  gr.  3  (0.194)  at  a  time, 
instead  of  the  silver  nitrate  spray.  Good  reports  are  given  of  this 
method. 


CHAPTER  XIII 

CANCER  OF  THE  STOMACH  (CARCINOMA  VENTRIC- 
ULD— OTHER  TUMORS  OF  THE  STOMACH— AP- 
PARENT TUMORS  OF  THE  STOMACH— FOREIGN 
BODIES  IN  THE  STOMACH 

CANCER  OF  THE  STOMACH  (CARCINOMA  VENTRICULI) 

Frequency. — In  an  analysis  of  30,000  cases  of  cancer, 
W.  H.  Welch,  of  the  Johns  Hopkins  Hospital,  finds  the  stomach 
involved  in  21.4  per  cent.,  standing  next  in  frequency  to  uterine 
cancer.  Osier  states  there  were  150  cases  of  carcinoma  ventricuU 
in  8464  patients  admitted  to  the  hospital  wards.  Haberlin  gives 
41.  per  cent,  from  1877  to  1886  in  his  statistics,  while  Brinton  places 
it  at  about  25  per  cent.  Haberlin  demonstrated  that  gastric  cancer 
is  on  the  increase  in  Switzerland,  and  Joseph  D.  Bryant  shows  the 
same  in  the  United  States.  Its  frequency  seems  to  vary  in  different 
countries,  Griesinger  having  never  observed  it  in  Egypt. 

Age. — Welch  finds  that  three-fourths  of  his  cases  occurred 
between  the  ages  of  forty  and  seventy.  Osier  analyzes  150  cases 
as  follows : 

Between  twenty  and  thirty  years,  6  cases;  from  thirty  to  forty, 
17;  forty  to  fifty,  38;  fifty  to  sixty,  49;  sixty  to  seventy,  36;  seventy 
to  eighty,  4. 

Fifty-eight  per  cent,  occurred  between  forty  and  sixty,  the 
youngest  case  was  twenty-two.  Welch's  statistics  show  the  majority 
of  cases  between  forty  and  sixty.  The  maximum  liability  to  cancer 
of  the  stomach  is,  therefore,  between  the  ages  of  forty  and  sixty. 
Two  cases  of  congenital  carcinoma  have  been  reported  and  also  a 
few  cases  under  the  age  of  thirty. 

Sex. — Welch  finds  cancer  of  the  stomach  shghtly  more  frequent 
among  men,  1233  men  to  981  women;  and  Osier  in  150  cases,  126 
males  and  24  females.  Statistics  vary  somewhat  regarding  per- 
centages, but  it  seems  to  preponderate  in  males. 

Race. — Among  150  cases  at  the  Johns  Hopkins  Hospital,  there 
were  131  among  the  whites  and  19  among  the  blacks.  The  ratio 
of  colored  patients  to  white,  however,  in  our  hospitals  is  small. 

Heredity. — Since    several    members    of    one    family    have    been 
afflicted  with  cancer,  many  are  inclined  to  believe  heredity  plays  a 
part.     Delafield^  and  Prudden    hold    that  "while  the  influence  of 
1  Handbook  of  Pathologic  Anatomy  and  Histology. 
240 


CANCER   OF   the;    STOMACH    (CARCINOMA    VENTRICULl)  24 1 

heredity  is  difficult  to  estimate,  there  are  a  few  well  authenticated 
cases  of  the  remarkable  prevalence  of  malignant  tumors  in  families 
within  a  few  generations." 

The  statistics  of  Williams  showed  that  in  235  cases  of  carcinoma 
of  the  uterus  or  breast,  9  per  cent,  gave  a  history  of  carcinoma  in 
the  father  or  mother,  while  in  nearly  20  per  cent,  there  was  evidence 
of  carcinoma  in  the  family ;  though  such  statistics  are  suggestive  and 
indicate  that  an  hereditary  predisposition  to  the  development  of 
tumor  may  exist,  this  does  not  account  for  the  immediate  excitement 
of  the  growth  of  tumors  and  is,  as  Menestrier  has  urged,  but  one  of 
the  examples  of  hereditary  disposition  which  is  observed  in  many 
forms  of  disease,  such  as  infections,  cerebral  apoplexy,  etc. 

Williams  cites  the  fact  that  the  father,  brother,  and  two  sisters 
of  Napoleon  died  of  cancer  of  the  stomach,  to  which  he  himself 
succumbed. 

William  S.  Bainbridge,^  who  has  extensively  investigated  the 
question,  believes  that  the  hereditary  acquirement  of  cancer  requires 
much  more  study  before  definite  conclusions  can  be  formulated,  and 
in  this  I  agree. 

Etiology. — Traumatism  has  been  given  as  a  frequent  cause  of 
cancer  of  the  stomach,  but  Osier  reports  only  i  case  in  his  series. 
Probably  attention  is  drawn  to  this  part  by  reason  of  the  injury,  and 
the  tumor  is  thus  recognized  more  early.  Cider,  sour  wines,  mental 
worry,  and  nervous  strain  have  been  suggested  as  predisposing 
causes,  but  they  have  no  influence. 

As  the  muscular  fibers  of  the  cardia  and  pylorus  undergo  frequent 
expansion  and  contraction,  and  are  subject  to  more  work  than  other 
portions  of  the  stomach,  Brinton  believes  the  necessarily  increased 
nutrition  of  these  parts  may  favor  glandular  proliferation  and  be 
productive  of  a  neoplasm. 

Some  consider"  chronic  inflammatory  disease  of  the  mucous 
membrane  of  the  stomach  to  be  a  predisposing  factor  in  the  produc- 
tion of  carcinoma,  notably  the  polypoid  form  of  chronic  gastritis 
(Menestrier).  As  a  rule,  carcinoma  develops  without  a  previous 
history  of  long-standing  gastric  disturbance,  and  I  agree  with  Ewald 
and  Einhorn  in  believing  these  conditions  have  no  influence. 

The  gastritis  found  with  cancer  is  a  secondary  condition.  The 
development  of  cancer  on  an  ulcer  scar  has  been  clinically  demon- 
strated by  Hauser.  Haberlin  places  about  7  per  cent,  of  cases  as 
occurring  in  this  manner,  while  Moynihan  gives  60  per  cent.,  and 
William  Mayo  36  per  cent. 

Regarding  the  parasitic  origin  of  cancer  and  its  infectious  nature 
there  is  much  dispute.  Scheurlein  beheved  he  had  discovered  a 
bacillus,  but  later  researches  demonstrated  his  error. 

Gaylord,   Park,   and   Adami  hold  to  the  parasitic  theory,   and 
Gaylord  states  that  in  all  the  organs,  including  the  blood  taken  from 
1  Boston  Medical  and  Surgical  Journal,  June  27,  1907. 
16 


242  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

cases  dying  of  cancer,  certain  organisms  (parasites)  are  found.  He 
has  inoculated  guinea-pigs  and  dogs  with  peritoneal  fluid  from  a 
human  abdominal  tumor  and  produced  adenocarcinoma  in  the  lung 
and  liver.  Coley  has  secured,  in  a  few  cases,  good  results  in  the 
treatment  of  cases  chiefly  of  sarcomata  and  of  a  few  cases  of  carci- 
noma by  the  injection  of  blood-serum  of  horses  treated  by  erysip- 
elas cocci,  and  I  have  personally  seen  a  favorable  result  in  i  case  of 
kidney  sarcoma. 

Psorosperms  have  been  found  in  cancer  cells,  but  it  has  not  yet 
been  proved  whether  they  are  real  psorosperms  or  dried-up  and 
changed  cells.  Beard's  recent  theory  and  his  suggestion  of  the  use 
of  trypsin  in  the  treatment  of  cancer  is  still  in  the  experimental 
stage.  We  must  confess,  so  far  the  origin  of  cancer  has  not  yet  been 
determined,  though  I  believe  it  will  eventually  be  demonstrated  to 
be  due  to  some  bacillus  or  parasite. 

Morbid  Anatomy. — Waldeyer  demonstrated  that  cancer  of  the 
stomach  originated  from  the  glandular  structure  of  the  mucous 
membrane,  being  an  atypic  proliferation  of  the  epithelium  of  the 
glands.  Beginning  in  the  mucosa,  it  infiltrates  the  submucosa,  the 
muscular  coat,  and  extends  to  the  serosa.  Early  in  the  development 
of  the  disease  the  lymphatic  glands  become  enlarged,  especially  those 
of  the  lesser  curvature.  Metastatic  growths  may  take  place.  The 
cancerous  growth,  especially  of  a  certain  type,  may  slough  and  form 
irregular  ulcers. 

Varieties. — The  most  common  varieties  of  cancer  are  the 
cylindric-celled  adenocarcinoma  (or  epithelioma)  and  the  encephaloid 
or  medullary  carcinoma;  next  in  frequency  is  the  scirrhus,  and  least 
frequent,  the  colloid  cancer. 

1.  Adenocarcinoma  (Cylindric-celled)  or  Epithelioma. — This  type 
forms  soft  tumors,  of  firmer  consistency  than  the  medullary  type,  and 
sloughing  more  slowly.  Microscopically,  the  section  shows  elongated 
tubular  spaces  filled  with  columnar  epithelium,  and  the  intervening 
stroma  is  abundant.  Gradually  the  tubular  spaces  develop  into 
cell-nests.  There  is  frequently  infiltration  of  the  connective  tissue 
with  white  blood-corpuscles.  Cystic  degeneration  is  quite  common. 
Metastases  and  hemorrhage  may  occur. 

2.  Medullary  Carcinoma. — This  occurs  in  soft,  spongy,  f ungating 
masses,  which  involve  all  the  coats  of  the  stomach  and  usually 
ulcerate  early.  It  is  large  and  often  fiat,  projecting  above  the  mucous 
membrane  and  may  form  villous-Hke  projections,  or  a  cauliflower- 
like outgrowth.  It  is  soft  and  grayish  or  yellowish  white  and 
contains  many  blood-vessels  and  cells.  Microscopically,  it  shows 
scanty  stroma,  enclosing  alveoli  containing  irregular  polyhedral  and 
cyHndric  cells.  It  is  often  blackish  in  color,  due  to  hemorrhage 
(melanotic) ,  and  has  a  tendency  to  ulcerate.     Metastases  are  frequent. 

3.  Scirrhus  (Fibrous)  Carcinoma. — This  is  characterized  by  great 
hardness,  due  to  abundance  of  stroma  and  the  limited  amount  of 


CANCER    OF   THE    STOMACH    (CARCINOMA    VENTRICULl)  243 

alveolar  structure.  The  large  amount  of  connective  tissue  makes 
the  tumor  very  firm  and  compact.  It  cuts  almost  like  cartilage,  and 
on  section  has  a  yellow  or  grayish-white  appearance.  There  is  little 
tendency  to  ulcerate,  except  at  a  late  stage  superficially,  and  second- 
ary metastases  are  not  common.  It  is  seen  quite  frequently  at  the 
pylorus,  there  being  a  diffuse  thickening  and  hardening  of  the  wall 
and  then  a  contraction,  being  a  common  cause  of  stenosis.  The 
tumor  may  be  diffuse,  involving  all  parts  of  the  stomach,  when  it 
may  be  difficult  to  recognize  it  microscopically  from  cirrhosis  ventric- 
uli.  It  has  occurred  in  the  stomach  secondary  to  ovarian  cancer, 
and  as  a  part  of  a  diffuse  carcinomatosis,  with  involvement  of  the 
small  and  large  intestines.  It  may  be  combined  with  the  medullary 
form. 

4.  Colloid  Carcinoma. — This  type  of  cancer  is  peculiar  from  the 
fact  that  it  invades  widely  all  the  coats  of  the  stomach.  It  spreads 
with  great  frequency  to  the  neighboring  parts,  and  at  times  causes 
secondary  growths  of  the  same  nature  in  other  organs. 

The  appearance  on  section  is  distinctive,  shovving  large  alveoli 
filled  with  translucent  gelatinous  colloid  material.  This  is  often 
present,  even  to  the  naked  eye.  On  scraping,  no  cancer  juice  exudes, 
but  gelatinous  fragments. 

Various  transitional  forms,  from  one  variety  to  another,  are  often 
found.  Rarely  a  carcinoma  consisting  of  squamous  epithelium  may 
extend  from  the  esophagus  into  the  cardia. 

Brinton,  in  analyzing  180  cases  of  cancer,  finds  the  scirrhus  type 
to  be  most  common  (72  per  cent.),  the  medullary  next  in  f requeue v; 
though  other  observers,  notably  Osier,  consider  the  epithelioma 
to  be  most  frequent. 

Cancer  of  the  stomach  is  usually  primary,  though  secondary 
growths  have  been  reported. 

Cancer  may  also  extend  from  the  liver. 

Types  of  Growth. — Medullary  and  colloid  cancers  involve  large 
areas  of  mucous  membrane,  growing  little  above  the  surface,  being 
somewhat  flattened,  with  occasional  rough  nodulous  masses.  Blood 
extravasations  and  adhesions  to  neighboring  organs  are  of  frequent 
occurrence. 

The  scirrhus  variety  extends  usually  only  over  a  small  portion 
of  the  mucosa  and  may  develop  extensively  in  thickness,  growing 
in  depth  and  height.  The  latter  type,  however,  occasionally 
infiltrates  the  entire  stomach,  causing  a  contraction  of  the  organ 
(cancer  atrophicans). 

Secondary  Changes  in  the  Mucous  Membrane  of  the  Stomach. 
— Hammerschlag  has  investigated  the  gastric  mucosa  in  cases  of 
carcinoma  by  examining  fresh  pieces  of  mucous  membrane  removed 
in  cases  of  resection  of  the  pylorus  at  the  time  of  gastro-enterostomy, 
examining  also  the  section  of  the  stomach. 

When  the  hydrochloric  acid  secretion  was  intact,  there  were  no 


244  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

changes  in  the  mucous  membrane.  When  it  was  absent  and  lactic 
acid  present,  changes  occurred,  and  there  were  found  destruction 
of  the  rennet  glands  in  certain  areas  and  small-celled  infiltration  and 
formation  of  connective  tissue  in  the  gastric  mucosa,  also  mucoid 
changes  or  cystic  degeneration;  in  effect,  a  secondary  atrophic 
gastritis.  Eosinophile  cells  are  present.  Hypertrophy  of  the 
muscular  fibers  and  connective  tissue  has  been  observed.  Ewald 
has  also  noted  that  the  entire  mucosa  may  show  the  lesions  of  chronic 
gastritis.  It  is  interesting  to  learn  that  Fenwick  has  demonstrated 
that  atrophic  gastritis  may  occur  in  carcinoma  of  the  breast  and 
uterus. 

Location  of  the  Cancer. — The  development  of  the  cancer  may 
take  place  in  various  regions  of  the  stomach,  at  the  pylorus  or  cardia 
or  within  the  organ,  causing  variation  in  the  symptoms  according 
to  location,  and  in  each  case  necessitating  a  special  plan  of  treatment. 

Welch's  analysis  of  1300  cases  is  as  follows:  Pyloric  region,  791 ; 
lesser  curvature,  148;  cardia,  104;  posterior  wall,  68;  the  whole  or 
greater  part  of  the  stomach,  61 ;  multiple  tumors,  45;  greater  curva- 
ture, 34;  anterior  wall,  38;  fundus,  19. 

In  Brinton's  cases,  60  per  cent,  were  found  at  the  pylorus.  The 
latter  is  evidently  the  point  of  selection. 

Wm.  Mayo  believes  70  per  cent,  involve  the  pyloric  region,  and 
that  60  per  cent,  originate  in  the  pylorus  or  within  3  inches  of  it. 

Changes  in  the  Shape  of  the  Stomach. — If  the  cancer  is  situated 
at  the  cardia,  the  stomach  is  usually  retracted  and  small  in  size, 
while  the  esophagus  above  the  stricture  is  dilated.  If  the  tumor 
constricts  the  pylorus,  the  stomach  will  be  dilated.  Gastroptosis  of 
varying  degree  may  be  present  by  reason  of  the  weight  of  the  tumor 
dragging  down  the  pylorus,  and  it  may  even  lie  down  in  the  pelvis. 
Adhesions  may  distort  the  shape  of  the  organ,  and  Riegel  reports 
an  hour-glass  contraction  of  the  stomach  resulting  from  cancer. 

Perforation. — Perforations  into  other  viscera,  through  the  skiti, 
or  into  the  general  peritoneal  cavity  are  rare.  The  aorta  has  been 
perforated.  Subphrenic  abscess  has  been  produced.  Perforation, 
however,  seldom  occurs. 

Cancerous  Metastases. — In  an  analysis  of  1574  cases  by  Welch, 
metastases  occurred  in  the  lymphatic  glands  in  551;  in  the  liver, 
475;  in  the  peritoneum,  omentum,  and  intestine,  357;  in  the  pan- 
creas, 122;  in  the  pleura  and  lung,  98;  in  the  spleen,  26;  in  the  brain 
and  meninges,  6;  in  other  parts,  92. 

The  abdominal  lymph-glands  are  usually  affected,  but  the 
cervical  and  inguinal  glands  are  sometimes  attacked. 

vSecondary  growths  occur  sometimes  at  the  navel  or  in  the  skin 
in  the  immediate  vicinity.  Infection  occurs  either  by  the  blood- 
vessels or  lymph-channels.  Direct  extension  by  continuity  ma}^ 
take  place. 

The  medullary  and  colloid  types  of  carcinoma  are  often  associated 


CANCER   OF    THE    STOMACH    (CARCINOMA    VENTRICULl)  245 

with  metastases.  Sometimes  numerous  small  cancerous  deposits 
occur  in  the  pleura.  The  microscope  will  differentiate  them  from 
tuberculosis,  though  they  have  occurred  together.  Rarely  metas- 
tases are  found  in  the  eyes. 

Symptoms. — There  are  general  symptoms  and  special  symptoms, 
depending  on  the  location  of  the  growth. 

General  Symptoms. — Usually  a  patient  of  middle  age,  fifty  to 
sixty  years,  up  to  a  short  time  previous — a  few  months  or  so — being 
in  perfect  health  and  having  had  no  gastric  symptoms,  will  begin  to 
complain  of  slight  dyspeptic  disturbance,  loss  of  appetite,  and  fulness, 
pressure,  and  discomfort  after  eating.  Belching  occurs,  also  more  or 
less  loss  of  sleep  and  loss  of  strength — the  symptoms  looking  much 
like  a  mild  gastritis.  The  tongue  is  usually  thickly  coated.  The 
symptoms  gradually  become  more  marked.  Rarely  the  attack 
begins  more  acutely.  The  feeling  of  discomfort  gradually  merges 
into  pain.  This  is  generally  not  of  the  severe  spasmodic  type  of 
ulcer,  but  is  continuous  in  character,  there  not  being  the  intermis- 
sions of  freedom  as  in  ulcer.  It  may  remit  somewhat.  The  pain  is 
at  times  increased  by  the  food,  but  is  often  intense  at  a  later  period 
after  eating  than  in  ulcer.  With  the  belching  there  is  at  first  regurgi- 
tation of  food,  later  vomiting,  usually  not  after  every  meal,  but  once 
or  twice  a  day.  This  is  a  prominent  symptom  when  the  growth 
causes  a  stenosis  of  the  pylorus. 

I  have  had  a  patient  at  the  Red  Cross  Hospital  with  car- 
cinoma of  the  greater  curvature  and  body  of  the  stomach,  an  inoper- 
able case  who  has  never  vomited  at  all,  the  motor  function  being 
fairly  good. 

Later,  hematemesis  occurs,  generally  several  times  in  succession, 
and  the  vomitus  is  of  coffee-ground  appearance  and  not  large  in 
quantity.  The  tumor  usually  becomes  palpable  at  this  time,  though 
often  earlier.  The  patient  has,  meanwhile,  been  steadih'  losing 
weight,  and  this  loss  becomes  more  and  more  marked  and  anemia 
and  cachexia  are  prominent.  He  becomes  more  weak  and  prostrated 
and  finally  dies  of  inanition  or  of  complications. 

These  general  symptoms  are  modified  by  the  position  of  the 
growth.     A  brief  analysis  of  the  symptoms  is  advisable. 

Anorexia,  or  loss  of  appetite,  occurs  in  about  85  per  cent,  of  the 
cases,  and  it  seems,  as  a  rule,  to  be  progressive.  There  is  at  times 
a  special  aversion  to  meat.  Riegel  believes  that  in  the  early  stages 
while  the  motor  power  remains  undisturbed,  the  appetite  remains 
good.  This  would  seem  as  if  toxemia  were  a  factor.  Boas  reports 
fair  or  increased  appetite  in  some  cases,  believing  loss  of  appetite  to 
be  due  to  lack  of  care  of  the  mouth  and  tongue.  The  toxemic 
theory  of  loss  of  appetite  seems  most  logical. 

Pain. — Pain  is  the  most  constant  symptom,  Osier  reporting  it  in 
130  out  of  150  cases,  Brinton  finds  it  in  92  per  cent,  of  his  patients, 
and  others  report  a  higher  percentage.     It  usually  begins  at  an  early 


246  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

date,  generally  in  the  epigastrium,  but  may  be  referred  to  the  hypo- 
chondriac regions,  the  sternum,  or  sometimes  extends  to  the  shoulders 
or  back.  It  may  be  lancinating  or  of  a  dull,  gnawing,  or  burning 
character.  There  may  be  tenderness  on  pressure  in  the  epigastrium. 
The  pain  does  not  occur  in  paroxysms  and  is  not  relieved  by  vomiting, 
as  in  ulcer.  It  is  continuous  and  never  entirely  disappears,  though 
it  may  remit.  As  a  rule,  it  is  less  intense  than  in  ulcer.  It  is  not 
relieved  at  the  end  of  gastric  digestion.  In  some  cases  it  may  occur 
more  markedly  after  eating,  though  it  is  not  especially  influenced 
thereby.  In  other  cases  there  may  be  more  of  a  painful  dull  feeling 
and  it  is  not  circumscribed  as  in  ulcer.  Sometimes  over  the  region 
of  the  tumor  the  pain  is  most  intense,  as  is  the  tenderness.  Head 
believes  there  are  areas  of  skin  tenderness  between  the  nipple  and 
umbilicus  in  front  and  the  fxfth  to  the  twelfth  dorsal  vertebrse  behind. 
Exacerbations  of  pain  are  caused  by  ulceration  of  the  growths  or  by 
formation  of  adhesions. 

Vomiting. — It  may  come  on  early,  but  more  usually  later.  Osier 
reports  it  in  128  cases  out  of  150;  and  Brinton  in  87  per  cent.  At 
first  it  occurs  at  rather  long  inter\^als,  but  later  may  be  present 
several  times  a  dav.  It  is  more  frequent  when  the  pylorus  is  involved, 
and  may  come  on  some  hours  after  the  ingestion  of  food,  or  at  times 
on  rising,  when  there  may  be  mucus  or  undigested  food  in  the  vomitus. 
It  may  be  offensive  in  odor  or  contain  changed  blood,  micro-organisms 
(Boas-Oppler  bacilli),  and  isolated  yeast-cells;  but  rarely  sarcinae, 
which  are  ynost  common  in  benign  stenosis.  Vomiting  can  occur, 
even  if  the  orifices  are  not  involved;  if  the  cardia  is  affected,  then 
regurgitation  is  characteristic. 

Extensive  involvement  of  the  anterior  or  posterior  wall  or  fundus 
may  be  present  without  vomiting. 

Hemorrhage  occurred  in  36  of  Osier's  cases  out  of  150;  w'hile 
Brinton  places  it  at  42  per  cent.  Riegel  believes  these  percentages 
too  low,  as  hemorrhage  may  be  occult,  or  often  not  examined  for  in 
the  vomitus  or  stool.  The  blood  is  occasionally  ejected  in  sufficient 
quantity  to  be  visible.  It  is  more  frequently  mixed  with  gastric  juice, 
food  and  mucus,  and  presents  a  blackish,  brownish,  or  coffee-ground 
appearance;  is  rarely  bright  red.  Osier  finding  it  in  3  cases.  The 
quantity  is  much  less  than  with  ulcer,  though  frequent  small  hemor- 
rhages may  occur.  Blood  in  the  stool  (melena)  may  accompany  it. 
though  this  is  rarer  than  in  ulcer.  A  fatal  hemorrhage  seldom 
occurs. 

Loss  of  Weight  and  Cachexia. — Progressive  emaciation,  especially 
if  the  disease  is  running  a  rapid  course  or  has  existed  for  some  time, 
is  a  consistent  feature.  In  the  earlv  stages  we  may  occasionally  see 
patients  who  appear  fairly  healthy,  or  have  little  loss  of  weight,  or 
at  times  temporary  improvement  may  occur  under  treatment. 
Unfortunately,  this  is  evanescent,  and  progressive  emaciation 
takes  place.     In  the  later  stages  this  is  marked,  as  are  the  sallow  skin 


CANCER   OF   THE    STOMACH    (CARCINOMA    VENTRICULl)  247 

and  peculiar  ashy  and  cachetic  appearance,  with  loss  of  strength 
proportionate  to  the  loss  of  weight. 

The  Blood. — Anemia  is  present  in  a  large  proportion  of  cases; 
when  pyloric  stenosis  occurs  with  dilatation  and  insufhcient  water 
absorption,  on  account  of  the  concentration  of  the  blood  the  number 
of  red  cells  may  not  be  greatly  reduced. 

The  average  count  in  59  of  Osier's  cases  was  3712,  186  per  cmm. 
Average  of  the  hemoglobin  was  44.9  per  cent. 

Schneyer^  has  shown  that  normal  digestive  leukocytosis  is  absent 
in  gastric  cancer,  and  that  the  number  of  leukocvtes  during  diges- 
tion and  fasting  is  the  same.  Osier  claims  that  only  54  per  cent, 
gave  positive  reaction. 

Leukocytosis  is  present  in  gastric  carcinoma,  usually  of  mild  de- 
gree, and  rarely  above  12,000  to  15,000.  Eosinophilia  is  usuallv  pres- 
ent and  suggestive.  We  find  some  cases  without  apparent  tumor,  in 
which  the  blood  count  is  so  low  as  to  be  suggestive  of  pernicious 
anemia,  but  the  absence  of  megaloblasts  and  the  presence  of  leuko- 
C5rtosis  speak  for  cancer. 

Tumor. — In  connection  with  the  symptoms,  the  presence  of 
a  tumor  in  the  gastric  region  is  a  reliable  diagnostic  point.  If 
large  and  superficial,  it  is  readily  detected.  In  Osier's  150  cases, 
tumor  w'as  detectable  in  115.  The  methods  of  determination  are  as 
follows : 

1.  Inspection. — Position  should  be  dorsal  and  the  knees  flexed 
to  relax  the  abdomen.  In  some  cases  a  protrusion  can  be  seen  in  the 
gastric  region  below  the  ensiform  or  at  the  margin  of  the  ribs.  If 
there  is  dilatation,  the  lower  cur\'ature  of  the  stomach  may  appear 
as  an  arched  line  below  the  umbilicus,  moving  up  and  dowri  during 
respiration.  Peristaltic  movements  are  present  w'ith  stenosis. 
With  gastroptosis,  the  lesser  curvature  may  be  seen  at  times  and  the 
tumor  situated  thereon  moving  during  respiration.  If  the  tumor  is 
at  the  pylorus,  it  mav  draw  the  stomach  downward  and  the  pro- 
trusion may  be  seen  low  down  in  the  abdomen  or  even  at  the  pelvic 
brim.  Pulsation  from  the  aorta  may  be  transmitted  to  the  tumor. 
Intrinsic  movements  in  the  hypertrophied  muscularis  may  cause 
the  tumor  to  appear  and  disappear.  A  subcutaneous  umbilical 
nodule  can  at  times  be  observed. 

Inspection  with  the  patient  standing,  as  suggested  by  Knapp, 
should  be  carried  out  in  any  case,  as  the  tumor  can  at  times  be  thus 
more  readily  appreciated.  Frequentlv,  simple  inspection  gives  no 
information. 

2.  Percussion. — There  is  dulness  on  percussion,  or  a  dull  tym- 
panitic note  over  the  tumor,  which  can  be  differentiated  from  the 
surrounding  tympanites.  Auscultatory  percussion  for  its  determina- 
tion is  described  and  illustrated  in  Chapter  X,  pages  75  and  76. 

3.  Palpation. — This  is  usually  quite  reliable.     It  determines  the 

^  Berliner  klin.  Wochenschr.,  1894,  No.  41. 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


position  and  size  of  the  growth,  whether  hard  and  nodular,  or  smooth, 
its  respirator 3^^  motihty,  and  whether  it  is  painful. 

It  is  difficult  to  recognize  a  tumor  on  the  posterior  stomach  wall 
unless  it  is  thin  and  the  stomach  empty.  On  the  lesser  curvature, 
with  the  stomach  in  the  normal  position,  it  can  only  be  felt  on  forced 
inspiration. 

4.  Respiratory  Motility. — Tumors  of  the  curvatures  show  greater 
respiratory  motility  than  those  of  the  pylorus.  When  the  latter  is 
adherent  to  the  liver,  it  follows  the  excursion  of  the  diaphragm. 

Tumors  are  smaller  to  the  palpating  finger  than  they  are  found  to 
be  on  operation. 

5.  Inflation. — This  is  of  value  in  aiding  inspection  and  also  in 
determining  whether  the  growth  is  connected  with  the  stomach,  if 
it  be  adherent,  and  in  some  cases  the  position  of  the  tumor  in  the 

organ.  Air  can  be  employed  for  the  purpose 
or,  more  easily,  carbonic  acid  gas  by  the 
method  already  described. 

If  the  tumor  lies  in  close  contact  with 
the  liver  and  moves  away  from  it  during 
inflation,  the  diagnosis  of  tumor  of  the 
stomach  is  evident,  and  the  liver  and  gall- 
bladder are  excluded.  If  this  does  not 
occur,  there  may  be  adhesions  or  involve- 
ment of  both  organs.  If  the  tumor  changes 
its  position  during  inflation,  there  are  prob- 
ably no  marked  adhesions  with  the  neigh- 
boring organs,  an  important  fact  in  refer- 
ence to  operative  procedure. 

A  tumor  of  the  pylorus  generally  moves 
to  the  right  and  downward  on  inflation; 
and  if  held  in  this  position  by  the  hand 
will  not  ascend  during  expiration — expira- 
tory fixation  (Minkowski).  If  adherent  to 
the  liver,  it  will  move  upward. 
Tumors  of  the  posterior  wall  and  lesser  curvature  that  are  palpable 

before  inflation  are  frequently  no  longer  so  thereafter.     With  gas- 

troptosis,  however,  the  tumor  would  be  palpable,  but  lie  higher  up. 
A  tumor  of  the  greater  curvature  descends  when  the  stomach  is 

inflated  and  occupies  the  lowest  border  of  the  area  of  inflation ;  it  is 

freely  movable  on  respiration. 

The  position  of  the  tumor  should  be  marked  on  the  abdominal 

wall  before  inflation  for  a  basis  of  comparison.     Inflation  of  the  colon 

sometimes  aids  in  the  location  of  the  growth. 

6.  Transillumination  of  the  Stomach. — This  method  is  of  value 
for  the  early  recognition  of  tumors,  but  only  if  they  lie  on  the  anterior 
surface,  on  the  curvatures,  or  at  the  pylorus.  With  the  circum- 
scribing gastrodiaphane  the  lesser  curvature  can  be  explored.     The 


Fig.  127. — Composite 
from  three  patients  show- 
ing dark  areas  in  trans- 
ihuminated  stomach,  pro- 
duced by  carcinomata 
of  the  curvatures  and 
pylorus. 


CANCER   OF    THE    STOMACH    (CARCINOMA    VENTRICULl)  249 

method  with  fluorescent  media  is  preferable.  The  tumor  being 
opaque,  appears  as  a  dark  spot  projecting  into,  or  within,  the  trans- 
illuminated  area;  on  top,  when  the  lesser  curvature  is  involved; 
below,  if  the  greater  curvature;  to  the  right,  if  the  pylorus  (Fig.  127). 

Temperature. — This  is  not  a  regular  symptom,  but  often  appears 
in  the  later  stages.  It  occurred  in  74  of  Osier's  150  cases.  It  is  of 
an  intermittent  type  and  rarely  runs  over  101°  F.  Chills  have 
occasionally  been  associated.  Fever  is  probably  due  to  some  inflam- 
matory process,  or  to  toxic  absorption  from  the  growth. 

Constipation  occurs  in  the  majority  of  cases  and  is  obstinate  and 
marked;  occasionally  there  is  diarrhea,  due  to  food  decomposition 
or  to  scybalae,  causing  irritation  of  the  intestinal  canal,  or  as  a  ter- 
minal symptom  due  to  sloughing  of  the  cancer. 

Coma  similar  to  diabetic  coma  may  occur,  and  is  believed  to  be 
due  to  acid  intoxication. 

Thrombosis  of  the  femoral  vein  is  an  occasional  symptom.  Osier 
reports  general  thrombosis  of  the  superficial  veins  in  one  case. 

Edema. — Swelling  of  the  ankles  frequently  occurs  toward  the 
close,  ascites  and  general  anasarca  sometimes  are  present,  and  the 
latter  may  appear  early. 

Metastases  have  been  described.  A  small  nodule  appearing  at 
or  near  the  umbilicus,  though  rather  rare,  may  aid  in  the  diagnosis. 

Multiple  neuritis  is  an  occasional  complication. 

Perforation  is  rare. 

Tetany  is  a  rare  complication,  but  has  occurred  with  malignant 
stenosis  of  the  pylorus  with  ectasia. 

Urine. — Excessive  nitrogen  execretion  has  been  found  in  some 
cases,  but  is  not  constant.  Dimiinution  of  the  chlorids  is  quite 
frequent,  while  indicanuria  is  common.  Glycosuria,  acetonuria, 
and  peptonuria  have  been  described. 

Peptonuria  indicates  absorption  from  an  ulcerated  area.  Neph- 
ritis is  often  present,  but  would  be  expected  in  advanced  age. 

Special  Symptoms  Produced  by  the  Location  of  the  Growth. — 
(a)  Cancer  of  the  Cardia. — One  of  the  first  and  an  important  svmp- 
tom  is  dysphagia.  The  patient  finds  that  there  is  some  impediment 
to  the  entrance  of  solid  food  into  the  stomach  and  assists  it  by 
drinking  water.  The  condition  gradually  grows  worse.  Later  it  is 
impossible  to  take  solid  food  at  all,  as  it  sticks  in  the  esophagus, 
causing  much  discomfort,  and  is  finally  regurgitated,  often  with 
considerable  straining  or  retching.  Finally,  most  of  the  fluid  even 
is  returned.  There  are  often  severe  pains  behind  the  end  of  the 
sternum  and  burning  sensations.  Mucus  is  sometimes  ejected  with 
the  food,  and  occasionally  blood.  The  cervical  lymph-glands  are 
often  enlarged.  Bronchitis  or  bronchopneumonia  are  frequent 
terminal  events. 

Physical  Examination. — The  stomach  is  of  normal  size  or,  in  some 
cases,  contracted ;  the  swallowing  sound   is  occasionally  absent   or 


250  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

heard  in  fifteen  to  twenty  seconds  instead  of  in  the  normal  period 
of  seven,  though  this  is  not  invariably  true. 

Examination  of  the  esophagus,  preferably  with  soft  stomach-tubes 
of  different  sizes ,  should  be  made.  The  position  of  the  stricture  can 
be  noted  by  marking  on  the  tube  at  the  teeth  when  resistance  to  its 
passage  is  first  encountered,  and  measuring  the  distance  from  the 
mark  to  the  tip  of  the  tube.  Smaller  tubes  are  then  employed,  until 
one  of  sufficiently  small  caliber  is  secured  to  enter  the  stomach. 

In  this  way  the  degree  of  stenosis  can  be  determined.  Much 
force  should  never  be  used.  In  some  cases  it  may  be  necessary  to 
employ  a  stiff er  tube  of  silkworm  or  bougies  of  varying  sizes,  of 
which  Einhorn's  divisible  instrument  is  convenient  (Fig.  128). 

The  soft  stomach-tube,  with  openings  at  the  tip  and  side,  is  of 
value  for  safety;  by  pinching  the  tube  before  withdrawal,  blood, 
either  fresh  or  decomposed,  of  foul  odor  or  mixed  with  mucus,  may  be 
found  within  it,  which  in  conjunction  with  the  other  symptoms  is 
suggestive  of  malignancy.     Occasionally   a  small  tumor  fragment 


Fig.  128. — Einhorn's  divisible  esophageal  bougie. 

may  be  removed,  which  should  be  submitted  to  microscopic  examina- 
tion. With  malignant  stricture  of  the  esophagus,  dilatation  above 
the  point  of  stenosis  and  retention  of  food  are  associated.  It  also 
occurs  in  benign  stricture  from  syphilis  or  from  traumatism  from 
burns  by  acids  or  alkalis  or  with  congenital  stenosis  of  the  esophagus, 
a  rare  condition. 

After  the  ingestion  of  suspended  bismuth,  examination  with 
the  x-rays  and  the  fluoroscope  will  aid  in  determining  the  site  of  the 
stricture.  This  is  of  special  value  when  it  is  not  desirable  to  use  the 
bougie. 

Aspiration  of  the  esophagus  above  the  seat  of  stricture  after  a 
small  test  meal,  and  then  the  passage  of  a  smaller  tube  and  aspiration 
of  the  stomach  contents,  and  a  differential  examination  of  the 
contents  are  not  necessary  for  diagnosis,  though  they  have  been 
recommended. 

The  food  removed  from  the  esophagus  would  present  the  appear- 
ance as  when  swallowed,  and  there  would  be  no  hydrochloric  acid ; 
while  in  the  stomach  the  particles  would  be  finer,  the  reaction  acid, 


CANCER    OF   THE    STOMACH    (CARCINOMA    VENTRICULl)  25 1 

and  free  hydrochloric  acid  might  or  might  not  be  present.  This 
is  also  true  of  the  ferments.  It  has  been  demonstrated  by  Moore 
and  Friedenwald^  that  in  cancer  of  other  organs  than  the  stomach, 
there  may  be  diminution  or  absence  of  free  hydrochloric  acid  in  the 
gastric  contents,  and  this  occurs  at  times  in  cancer  of  the  cardia. 
The  presence  of  stricture  and  dysphagia ,  the  age  of  the  patient,  and 
the  general  symptoms  are  diagnostic. 

With  diverticula  of  the  esophagus,  which  usually  occur  at  the 
junction  of  the  pharynx  and  gullet,  there  is  generally  a  swelling  in  the 
neck,  which  can  be  diminished  by  pressure  (the  contents  expressed), 
and  symptoms  of  cancer  are  absent. 

Spasm  of  the  esophagus  usually  occurs  in  nervous  patients,  and 
the  tube  when  passed  is  temporarily  arrested.  Larger  tubes  often 
pass  more  readily  than  the  small  ones.  There  are  no  symptoms  of 
malignancy. 

(b)  Cancer  of  the  Pylorus. — The  chief  subjective  symptoms  are 
pain,  a  full  feeling  in  the  stomach  and  other  dyspeptic  symptoms, 
and  frequent  attacks  of  vomiting.  Just  before  emesis  there  are 
often  severe  exacerbations  of  pain,  due  to  the  contractions  of  the 
stomach  and  the  effort  to  expel  the  contents  through  the  pylorus. 

The  vomitus  is  generally  large  in  amount  (i  to  2  liters)  and  may 
consist  of  food  taken  the  day  before.  Motor  insufRciency  is  marked, 
the  contents  on  aspiration  being  found  to  consist  of  more  or  less 
decomposed  food,  when  the  fasting  stomach  is  examined.  The 
particles  of  food  are  often  quite  large  and  obstruct  the  openings  of 
the  tube,  and  are  difficult  to  remove  by  lavage. 

Physical  Examination. — Peristaltic  unrest  is  a  frequent  symptom. 
Dilatation  of  the  stomach  is  present,  as  determined  by  the  methods 
of  examination  described.  Gastroptosis  may  be  present.  Fre- 
quently a  tumor  can  be  detected  lying  in  the  epigastrium  to  the 
right  of  the  median  line  or,  if  ptosis  is  present,  at  a  lower  level. 

(c)  Cancer  of  the  Body  of  the  Stomach. — -Pain,  anorexia,  and  other 
symptoms  are  manifested.  Vomiting  occurs  in  some,  but  in  many 
cases  is  absent.  The  vomitus  contains  food  and  occasionally  coffee- 
grounds,  the  food  is  more  fmelv  divided. 

The  tumor  frequently  lies  to  the  left  of  the  median  line;  but  if 
on  the  upper  curvature  or  posterior  surface  of  the  stomach,  is  not 
always  detectable. 

There  is  motor  insufficiency  of  a  slight  or  moderate  degree  due 
to  infiltration  of  the  muscular  tissue  bv  the  growth,  and  occasionally, 
if  the  tumor  be  large  and  on  the  greater  curvature,  a  slight  dilatation. 

Laboratory  Diagnosis. — In  conjunction  with  cUnical  symptoms, 
analysis  of  the  gastric  contents  and  microscopic  examination  aid  in 
establishing  the  diagnosis  of  cancer  of  the  stomach. 

Gastric  Contents. — Golding  Bird,  in  1842,  first  refers  to  the 
diminution  or  absence  of  hydrochloric  acid  in  gastric  cancer,  but 
^New  York  Medical  Journal,  August  24,  1907. 


252  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Von  der  Velden,  in  1879,  first  studied  the  question  in  a  scientific 
manner. 

For  accuracy  the  vomitus  should  be  examined;  analysis  of  the 
gastric  contents  and  microscopic  examination,  after  the  test  break- 
fast, should  be  made  and  the  stomach  washed  out.  If  small  frag- 
ments of  mucosa  are  found,  these  should  be  examined,  as  suggested 
by  Hemmeter  and  Einhorn. 

Vomitus. — Macroscopically,  undigested  meat-fibers  and  coarse 
food  particles  are  found;  the  quantity  is  variable,  depending  upon 
the  motor  functions.  Coffee-ground  material  is  present  in  many 
cases  and  often  a  foul  odor  in  advanced  cases. 


Fig.  129. — Gastric  contents  in  carcinoma.  Dark  ground  illumination  X  460: 
a,  Leukocyte;  b,  Boas-Oppler  bacilli;  c,  squamous  epithelium;  d,  yeast;  e,  mucous 
membrane  fragment  with  carcinomatous  cells  as  rarely  found  in  wash-water;  /, 
bacilli;  g,  wheat  starch  grain;  h,  sarcinae  (very  rare);  i,  fat-droplet;  ;,  cocci. 

Microscopically,  undigested  muscle-fibers,  remnants  of  vegetable 
material,  starch  granules,  fat  droplets,  numerous  fungi;  sarcincB  are 
rare;  yeast-celis  are  found  in  stagnating  contents,  though  usually 
as  isolated  specimens;  and  blood  and  Boas-Oppler  bacilli  (Fig.  129). 
Boas  and  Strauss  report  pus^  in  some  cases. 

Occult  blood  should  be  tested  for  by  Weber's  or  the  benzidin  or 
aloin  test,  if  none  appear  microscopically. 

Examination  of  Test  Breakfast. — Ewald's  or  Boas'  test  breakfast 
should  be  given,  and  one  hour  later  the  contents  aspirated  and 
examined.     Repeated  analyses  should  be  made. 

I.  Hydrochloric  Acid. — Out  of  94  of  Osier's  cases  of  gastric 
cancer,  in  84  free  hydrochloric  acid  was  absent;  and  in  40  cases, 

1  Pus  may  be  found  in  benign  ulceration,  as  in  Connor's  case,  as  well  as  in 
malignant  ulcer. 


CANCER   OF   THE    STOMACH    (CARCINOMA    VENTRICULI)  253 


Boas  found  it  absent  in  35.  In  the  first  stages  of  gastric  carcinoma, 
however,  free  HCl  is  diminished,  not  absent.  A  progressive  dimi- 
nution in  the  percentage  of  free  HCl  during  the  course  of  a  month  or 
more,  as  determined  by  frequent  examinations,  when  taken  in  con- 
sideration with  the  other  symptoms,  is  corroborative  of  cancer. 
Einhorn  reports  6  cases  of  gastric  cancer  in  which  free  hydrochloric 
acid  was  present  in  normal  or  excessive  quantity. 

In  gastric  cancer,  engrafted  on  gastric  ulcer,  free  HCl  (or  hyper- 
chlorhydria)  has  been  noted  in  the  earlier  stages,  often  with  pro- 
gressive diminution  accompanying  the  increased  development  of  the 
cancer.  I  have  seen  hyperchlorhydria  persist  in  quite  an  advanced 
stage,  notably  in  a  case  at  the  Red  Cross  Hospital,  which  was 
deemed  inoperable.  The  patient,  aged 
sixty-eight,  suffered  with  the  symp- 
toms of  gastric  ulcer  for  a  year,  fall- 
ing off  in  weight  from  240  to  200  lbs. 
There  was  then  a  slight  gain.  Later 
he  lost  steadily,  and  when  admitted 
to  the  hospital  weighed  149  lbs.,  was 
extremely  weak  and  cachectic,  with 
a  tumor  on  the  anterior  surface  of 
the  stomach,  involving  the  greater 
curvature,  and  with  the  clinical  symp- 
toms of  carcinoma,  except  the  gastric 
findings,  which  were  hyperacid,  with 
a  total  acidity  of  90  + ,  free  hydro- 
chloric acid  70  -1- .  The  position  of  the 
growth  is  shown  in  Fig.  130.  There 
was  only  slight  disturbance  of  motor 
function  and  no  vomiting.  Anemia, 
leukocytosis,  and  eosinophilia  were 
present. 

The    patient    gained     20    lbs.    in 
weight  under  trypsin  treatment  and 

proper  diet,  and  was  able  to  go  out  daily.  His  strength  markedly 
improved,  as  well  as  his  appearance.  The  growth  did  not  disappear. 
The  patient  returned  to  work  and  at  the  end  of  several  months  con- 
tracted pneumonia  and  died. 

We  know  that  free  hydrochloric  acid  is  markedly  diminislied, 
or  even  absent,  in  severe  catarrhal  gastritis,  and  is  absent  in  achylia 
gastrica.  Its  absence  is  not  pathognomonic  to  cancer,  but  taken  in 
conjunction  with  the  clinical  symptoms  is  confirmatory. 

2.  Lactic  Acid. — It  has  been  known  for  some  years  that  organic 
acids  were  increased  in  cancer  of  the  stomach  and  lactic  acid  was 
present;  but  to  Boas  must  be  given  the  credit  of  attaching  diagnostic 
significance  to  it  and  who  first  described  exact  quantitative  and 
qualitative  methods. 


Fig.  130. — Irregular  type  of 
carcinoma  under  trypsin  treat- 
ment at  Red  Cross  Hospital. 
Carcinoma  of  stomach,  anterior 
wall  involving  greater  curvature; 
slight  reduction,  of  motor  func- 
tion. Tumor  evident  by  palpa- 
tion, percussion,  and  gastro- 
diaphany.  History  of  ulcer  with 
carcinoma  engrafted.  Hyper- 
chlorhydria present. 


254 


DISEASES    OF   THE    STOMACH    AND    INTESTINES 


He  washes  the  stomach  and  gives  a  plate  of  barley  soup,  which 
contains  no  lactic  acid,  and  an  hour  later  aspirates  the  contents. 
Lactic  acid  should  be  examined  for  by  Uffelmann's  test  or  by  Boas' 
method.  Ewald's  test  breakfast  will  generally  suffice  for  practical 
purposes. 

In  most  cases  lactic  acid  is  present  in  considerable  quantity, 
though  occasionally  it  is  absent  when  free  hydrochloric  acid  is 
in  evidence.  In  non-malignant  stenosis  with  dilatation  it  has  been 
found,  so  it  cannot  be  said  to  be  absolutely  pathognomonic.  The 
absence  of  free  hydrochloric  acid  and  the  presence  of  lactic  acid  are 
confirmatory,  in  conjunction  with  other  symptoms. 

Boas-Oppler  bacilli  are  found. 
These  are  rods  of  considerable  length, 
frequentlv  joined  at  their  ends,  and 
form  long  angulated  threads,  stain- 
able  by  methvlene-blue  or  other  ani- 
line dyes  (Fig.  131)-  They  must  be 
distinguished  from  the  Leptothrix 
buccalis  (found  in  the  mouth).  A 
drop  or  two  of  Gram's  solution 
should  be  added  to  the  specimen. 
The  Boas-Oppler  stains  brown  with 
the  iodin,  the  leptothrix  blue. 

Gram's  solution  consists  of  iodin, 
I  part;  potassium  iodid,  2  parts; 
water,  300  parts. 

The  Boas-Oppler  bacillus  is  found 
in  about  80  per  cent,  of  cases  of  car- 
cinoma of  the  stomach;  also  rarely  in  non-malignant  stenosis  with 
dilatation  of  the  organ. 

With  absence  of  HCl,  an  alkaline  medium,  and  absence  of  stagna- 
tion, Paul  Cohnheim  also  holds  that  the  trichomonas  hominis,  megas- 
toma  entericum,  with  associated  amebae,  pus,  and  blood,  are  found 
in  carcinoma  of  the  stomach,  not  affecting  its  motility  (page  117). 

Pus. — The  detection  of  pus  in  the  gastric  contents  by  micro- 
scopic examination  is  of  diagnostic  value.  The  presence  of  blood,  or 
occult  blood,  is  also  important  before  the  tumor  is  palpable. 

Diagnosis. — -In  a  patient  of  forty-five  to  sixty  or  more  years  of 
age,  suffering  from  recent  gastric  disturbances  of  six  months'  or  a 
year's  duration,  or  less,  with  a  previous  history  of  good  health;  there 
being  continuous  pain,  frequently  epigastric  rigidity,^  rapid  loss  of 
weight  and  strength,  anorexia  with  or  without  vomiting,  motor  insuf- 
ficiencv  moderate,  or  great  with  marked  ectasia,  with  diminution  or 
absence  of  free  hydrochloric  acid,  lactic  acid  present;  Boas-Oppler 
bacilli  present ;  whether  or  not  there  be  tumor  detectable,  or  whether 
or  not  coffee-grounds  are  present  in  the  vomitus,  such  symptoms 
'  Anders,  N.  Y.  Med.  Jour.,  Nov.  21,  1908. 


Fig.  131. — Boas-Oppler  bacillus 
from  near  top  of  fluid  from  wash- 
ing in  case  of  gastric  cancer.  Ob- 
servation at  Pennsylvania  Hos- 
pital (Boston). 


CANCER    OF    THE    STOMACH    (CARCINOMA    VENTRICULi)  255 

should  be  considered  diagnostic  of  carcinoma  of  the  stomach.^  As 
already  noted  the  presence  of  pus  and  occult  blood  are  important. 

Rontgen  Rays. — Anders-  and  Pfahler  ^  hold  that  the  :r-rays  aid 
in  the  early  diagnosis  of  gastric  carcinoma.  The  new  growth  makes 
itself  evident  by  a  change  in  the  contour  of  the  stomach  wall ;  by 
disturbance  of  the  peristaltic  waves  at  certain  points;  at  times  by 
rigidity  and  contraction  of  the  stomach  wall;  by  adhesions  which 
prevent  the  free  motility  of  the  stomach  when  the  abdominal  walls 
are  contracted,  or  when  the  position  of  the  patient  is  changed;  and 
finally,  in  some  cases,  by  obstruction  to  the  passage  of  food.  The 
method  requires  great  care  even  by  an  expert,  and  may  be  an  aid 
later  in  connection  with  the  clinical  symptoms  and  phvsical  and  clin- 
ical examination. 

Differential  Diagnosis. — Apparent  Tumors  of  the  Stomach. — 
Prolapse  of  the  left  lobe  of  the  liver,  or  a  pulsating  aorta,  or  thickening 
of  part  of  the  abdominal  muscles  (recti)  are  referred  to  by  Einhorn 
as  being  mistaken  for  a  tumor  or  possibly  for  a  carcinoma  of  the 
stomach.  In  view  of  the  fact  that  with  these  conditions  gastrop- 
tosis  is  usually  associated,  the  history  is  a  long  one,  emaciation  is 
of  long  duration,  and  the  symptoms  of  cancer  are  absent,  the  mistake 
can  hardly  occur.  They  are  also  apt  to  be  present  in  younger 
patients.  Simple  adhesions  of  the  stom.ach  give  a  history  most  fre- 
quently of  gall-bladder  disease,  or  gastric  ulcer,  or  localized  peri- 
tonitis. Adhesions  are  frequently  present  with  cancer,  but  the 
symptoms  and  gastric  findings  are  of  carcinoma. 

Grave  Anemia  in  Carcinoma  Ventriculi,  without  Palpable  Tumor. — 
These  cases  must  be  differentiated  from  pernicious  anemia.  The 
type  occurs  with  mild  dyspeptic  symptoms.  The  blood-count  is 
rarely  below  2,000,000  per  cubic  millimeter;  there  is  absence  of 
megaloblasts  and  leukocytosis  is  present,  which  speak  for  cancer. 
There  is  a  lower  color-index,  as  in  secondary  anemia. 

In  addition,  the  acidity  of  the  gastric  contents  is  higher  than  \vith 
the  achylia  gastrica  of  pernicious  anemia,  and  lactic  acid  is  present 
in  cancerous  anemia.  If,  therefore,  we  have  gastric  symptoms,  rapid 
loss  of  weight,  and  severe  anemic  s3^mptoms  in  an  elderly  patient, 
the  diagnosis  of  cancer  is  most  probable.  In  secondary  anemia  or 
chlorosis,  hyperchlorhydria  is  usually  associated. 

Syphilis. — This  may  present  symptoms  which  may  simulate 
carcinoma  of  the  stomach,  unless  thorough  examination  be  made. 
I  have  seen  three  types  of  this  class. 

I.  Sclerosis  of  the  Stomach. — A  male  patient,  aged  sixty,  had  lost 
30  lbs.  in  weight  within  a  period  of  a  year;  was  emaciated  and  weak, 

^  Neusser  and  R.  Schmidt  hold  that  Boas-Oppler  bacilli  are  more  easily  found 
in  the  stool  than  in  the  gastric  contents  and  aid  early  diagnosis  of  cancer.  Gram 
negative  stools  exclude  cancer  of  the  stomach; Gram ])ositive  stools,  uniform  sized 
Gram  positive  bacilli  (Boas-Op])ler  bacilli),  show  cancer  (Journal  Am.  Med. 
Assoc,  Nov.  6,  1909,  p.  1525,  by  P.  K.  Brown).  I  believe  the  Bacillus  aerogenes 
capsulatus  are  found,  and  their  deductions  probably  erroneous. 

^  New  York.  Med.  Jour.,  Nov.  21,  1908.  ^  Ibid.,  Aug.  21,  1909. 


256 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


suffering  from  gastric  symptoms  and  constipation.  On  examination, 
a  small  hard  mass  is  found  in  the  epigastrium  at  the  left  border  of 
the  ribs  (Fig.  132). 

It  was  demonstrated  to  be  a  hard  and  contracted  stomach, 
giving  the  feel  of  a  diffuse  scirrhous  carcinoma  of  the  organ.  The 
liver  was  diminished  in  size  and  hard.  Free  HCl  were  absent,  the 
findings  were  of  achylia  gastrica.  Syphilitic  scars  were  in  evidence 
and  the  patient  acknowledged  syphilis  ^  and  alcoholism. 

2.  Cirrhosis  of  the  Liver  {Left  Lobe — Syphilitic). — ]\Iale,  aged 
fifty-five,  had  lost  20  lbs.  in  a  few  mouths  and  suffered  from  gastric 
symptoms.  A  hard  mass  could  be  felt  in  the  epigastrium,  extending 
down  from  the  lower  border  of  the  left  ribs,  apparentlv  a  tumor  of 


Fig.  132. — Syphilitic  sclerosis  of 
stomach.  Physical  examination  of 
stomach  suggests  scirrhous  carcinoma 
(diffuse)  of  stomach. 


Fig-  133- — Syphilis.  Enlargement 
of  left  lobe  of  liver  overlapping  stom- 
ach. Transillumination  shows  mass, 
which  is  readily  palpable.  Side  view 
(gastrodiaphany)  shows  the  mass  not 
connected  with  the  stomach.  Free  HCl 
trace;  chronic  gastritis. 


the  lesser  curvature  of  the  stomach  involving  the  anterior  wall. 
Respiratory  movements  were  present.  Deep  palpation  elicited  a 
free  edge  and  gastrodiaphany  showed  an  opaque  mass,  but  on 
moving  the  instrument  a  lateral  view  demonstrated  the  mass  over- 
lapping the  stomach  (Fig.  133). 

Gastric  findings  were  a  trace  of  HCl  and  much  mucus  (chronic 
gastritis).  Syphilitic  scars  and  history  were  elicited.  Improvement 
followed  treatment  directed  to  the  stomach  and  syphilis. 

3.  Syphilitic  Stenosis  of  the  Pylorus,  Due  to  Gummatous  Tnmor, 
Simulating  Malignancy. — ]\Iale  patient,  aged  thirty-eight.  Weight, 
September,  1907,  196  lbs.  At  this  time,  anorexia,  pain  continuous 
in  character,  nausea,  and  occasional  vomiting  began.  These  symp- 
toms gradually  grew  worse  and  the  patient  steadily  lost  weight. 
Early  in  November  he  entered  a  local  hospital,  where  he  was  under 

^  The  demonstration  of  Wassermann's  reaction  is  diagnostic  in  doubtful  cases. 


CAN'CER    OF    THE    STOMACH    (CARCIXOMA    VENTRICULl)  257 


tufttrof/iot'  f^aJpable- 
/lor  visible  by      , 

TratiSiflinnitiat/on 


treatment  by  lavage,  etc.,  for  eight  weeks.  His  weight  on  leaving 
the  institution  was  137  lbs.  He  spent  two  months  at  a  western 
sanitarium,  where  he  grew  steadily  worse,  having  vomited  small 
quantities  of  blood  on  several  occasions.  He  was  given  morphin 
for  pain  and  subsequently  contracted  the  habit. 

At  the  end  of  March,  1908,  or  about  six  and  a  half  months  after 
the  first  appearance  of  symptoms,  he  entered  the  Red  Cross  Hospital. 
His  weight  w^as  119  lbs.  a  loss  of  77  lbs.,  epigastric  pain  nearly 
continuous,  increased  some  after  eating,  tenderness  in  the  epigastrium, 
peristaltic  unrest  of  the  stomach,  dilatation  to  one  finger  below 
umbilicus,  daily  vomiting.  There  were  marked  emaciation  and 
considerable  anemia,  but  not  the  cachectic  appearance  of  cancer. 
No  tumor  was  detectable  by  palpation  or  transillumination,  but  a 
sense  of  resistance  at  the  pylorus.  Frequent  gastric  analysis  invaria- 
bty  showed  free  HCl  absent  and  abundant  lactic  acid.  Morphin  w^as 
shut  off,  and  lavage,  diet,  and  careful  obser\'ations  w^ere  carried  out. 
A  syphilitic  history  w  as  secured. 

On  account  of  the  age  of 
the  patient,  the  syphilitic  his- 
tory and  the  absence  of  true 
cachexia,  in  spite  of  the  gastric 
findings,  I  believed  the  stenosis 
to  be  non-maUgnant  (syphilitic) 
and  advised  operation.  This 
was  duly  performed.  There  was 
a  hard  mass  on  the  posterior 
wall  of  the  p^'lorus,  about  the 
size  of  an  English  walnut,  block- 
ing the  passage;  no  glandular 
involvem.ent  (Fig.  134).  As  the 
patient  was  in  poor  condition, 
rapid  gastro-enterostomy  was 
performed.  He  vomited  once 
after  operation.  Mercurial  in- 
unction a.nd  iodids  were  given, 
and  the  patient  left  the  hospital 

in  good  condition.  He  would  unquestionably  have  died  from 
inanition  unless  stomach  drainage  had  been  instituted,  in  spite  of 
specific  treatment. 

Cancer  Engrafted  on  an  Ulcer. — This  condition  I  believe  is  a 
quite  frequent  occurrence.  There  is  generally  a  gradual  change  in 
the  symptoms  and  character  of  the  gastric  secretion,  a  gradual  dimi- 
nution of  free  HCl,  though  Riegel  has  brought  to  our  attention  that 
in  this  type  the  excessive  production  of  hydrochloric  acid  often  per- 
sists for  a  long  time,  and  in  some  rapidly  fatal  cases  may  be  present 
^tntil  death. 

In  these  cases  the  diet  and  medication  directed  to  the  ulcer  fail 
17 


Fig.  134. — Syphilitic  stenosis  of  pylorus 
due  to  gumma  simulating  malignancy. 
Transillumination  shows  dilatation,  but 
no  tumor.  Growth  found  at  operation 
lying  on  posterior  wall  of  pylorus.  Gas- 
tric findings  of  carcinoma,  but  no  ca- 
chexia. 


258 


DISEASES    OF   THE    STOMACH    AND    INTESTINES 


faJ^ble  Tumor - 


as  soon  as  the  malignant  condition  sets  in.  The  pain  increases  and 
is  continuous.  There  is  a  dislike  or  even  loathing  for  food.  There 
is  rapid  loss  of  weight  and  the  typical  cachexia  appears — a  change 
from  the  facies  of  ulcer.  Hematemesis  is  more  frequent,  especially 
as  occult  hemorrhage. 

This  type  should  be  considered  in  order  to  avoid  error.  I  have 
already  referred  to  a  patient  of  this  class  (hyperchlorhydria) ,  with  a 
marked  growth,  cancer  engrafted  on  an  ulcer. 

Aneurism  of  the  Celiac  Axis  Simulating  Carcinoma  of  the  Pylorus. — 
The  possibility  of  this  error  is  interesting.  A  negro  patient,  aged 
forty-five,  was  seen  by  me  at  Roosevelt  Hospital  several  years  ago 

at    the    request    of    William    H. 
Thomson. 

The  illustration  (Fig.  135) 
shows  the  position  of  the  stomach 
by  inflation  and  that  of  the  mass 
by  palpation,  it  not  being  visible 
by  transillumination.  The  tumor 
disappeared  on  inflation,  diagnostic 
of  a  posterior  position. 

There  were  vomiting,  gastric 
symptoms,  such  as  pain,  anorexia, 
etc. ,  and  a  loss  of  weight  of  40  lbs. 
in  three  months.  The  patient  was 
very  weak.  Dilatation  to  below 
the  umbilicus.  Gastric  analysis; 
no  free  hydrochloric  acid;  lactic 
acid  was  present. 
A  palpable  tumor,  the  size  of  a  small  egg,  was  present  in  the 
epigastrium,  in  which  there  was  slight  pulsation,  but  no  bruit  or 
thrill.  From  the  history  and  results  of  examination  it  seemed  to  be 
a  carcinoma  on  the  posterior  wall,  involving  the  pylorus,  with 
pulsation  transmitted  from  the  aorta. 

The  possibility  of  aneurism  was  considered.  Exploration  by 
G.  Brewer  showed  an  aneurism  of  the  celiac  axis  pressing  on  the 
pylorus  posteriorly.  The  resulting  occlusion  of  the  pylorus  and 
circulatory  disturbances  from  the  aneurism  were  responsible  for 
the  ectasia  and  changes  in  the  gastric  secretion. 

Syphilis  and  aneurism  must  thus  be  considered  in  our  differential 
diagnosis. 

The  following  are  the  chief  diagnostic  points  between  cancer  of 
the  stomach  and  other  conditions: 

Cancer. — Age, usually  forty  to  seventy;  tongue  coated;  symptoms 
progressive  and  of  short  duration — a  few  months  to  a  year;  emacia- 
tion rapid;  cachexia;  repeated  small  hemorrhages,  but  not  always; 
pain  continuous,  not  paroxysmal,  with  no  periods  of  relief,  and  not 
referring  especially  to  the  digestion  period ;  anorexia ;  vomiting  once 


Fig.  135. — Aneurism  of  celiac  axis 
with  symptoms  simiulating  carcinoma 
of  pylorus.  No  tumor  visible  by  trans- 
illumination. Tumor  disappears  on 
inflation. 


CANCER    OF   THE    STOMACH    (CARCINOMA    VENTRICULl)  259 

or  twice  a  day;  later,  coffee-grounds  in  vomitus;  at  times  only  occult 
blood  in  vomitus  or  stool ;  ectasia  if  the  pylorus  is  involved ;  tender- 
ness over  the  gastric  region;  no  relief  of  pain  by  vomiting;  anemia; 
free  HCl  diminished  or  absent;  lactic  acid  present,  also  pus;  sarcinse 
rare  and  when  present,  few;  Boas-Oppler  bacilli  in  most  cases;  in 
some  vomiting  of  blood  (coffee-grounds),  small  in  quantity  and  often 
repeated  several  times;  melena  slight.  Leukocytosis  moderate  and 
eosinophilia  present.  Mucus  present  in  some  cases.  Dysphagia  and 
regurgitation  if  involvement  is  at  cardia. 

Ulcer. — Age  usually  twenty  to  forty;  pain  paroxysmal  and  worse 
after  eating;  remissions  of  pain,  and  relieved  by  vomiting;  pain  in 
epigastrium  and  in  the  back;  local  circumscribed  tenderness  in  the 
epigastrium  increased  by  pressure,  at  times  slight  tender  point  in  the 
back;  loss  of  weight;  anxious  expression  of  suffering;  no  cachexia; 
anemia;  vomiting  at  height  of  digestion;  appetite  good;  hyper- 
chlorhydria  usual;  vomiting  of  blood  in  large  quantity,  at  times  of 
bright  color ;  melena.     Blood  at  times  only  occult. 

Benign  Stenosis. — Dilatation  of  stomach;  peristaltic  unrest 
and  pain  (spasmodic)  preceding  vomiting;  long  history;  periods  of 
improvement;  hyperacidity  usual;  sarcinae  present  in  number; 
emaciation  but  no  cachexia;  vomiting  of  large  amount;  usually  no 
tumor,  and  if  present  very  small  and  smooth  on  palpation;  history 
of  previous  ulcer;  usually  no  blood,  as  ulcer  is  practically  healed  or 
contracting;   anemia   present;   no   leukoc>i;osis. 

Malignant  Stenosis. — Dilatation  of  stomach;  peristaltic  unrest; 
short  history;  no  period  of  improvement;  rapid  loss  of  weight;  pain 
continuous ;  cachexia ;  little  or  no  free  hydrochloric  acid ;  lactic  acid ; 
Boas-Oppler  bacilli;  vomiting  large  amount  and  often  odorous;  at 
times  coffee-grounds  in  vomit  from  ulceration  of  growth;  anemia 
marked;  leukocytosis. 

Chronic  Gastritis. — Long  history  of  dyspepsia ;  absence  of  cachexia ; 
no  lactic  acid;  less  anemia;  no  leukocytosis;  intense  pain  absent, 
more  feeling  of  discomfort;  no  real  pain  on  palpation;  mucus  in 
gastric  contents,  HCl  diminished  or  absent. 

Achylia  Gastrica. — Total  acidity  much  lower  than  in  cancer,  from 
4-f  to  2-f  or  less;  free  hydrochloric  acid,  pepsin  and  rennet  absent; 
no  mucus ;  scarcely  any  gastric  juice ;  food  particles  coarse  and  nearly 
dry;  course  long;  no  cachexia;  no  lactic  acid;  may  be  considerable 
loss  of  weight.  In  transitional  stage  (commencing)  some  claim 
mucus  is  present. 

Nervous  Gastralgia. — Patient  nervous  or  hysteric;  pain  irregular 
or  relieved  by  pressure;  free  intervals  from  pain;  appetite  variable; 
no  regularity  of  vomiting;  secretory  function  is  variable;  no  tumor; 
no  cachexia ;  character  of  food  makes  little  difference  as  to  symptoms. 

Carcinoma  of  the  gall-bladder  is  found  in  location  of  gall-bladder; 
follows  respiratory  movements  of  the  liver ;  shows  no  lateral  motility 
and  does  not  allow  expiratory  fixation.     Its  position  is  unchanged 


26o  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

if  the  stomach  is  inflated  with  air.  It  rarely  causes  dilatation  of 
the  stomach  unless  adhesions  form;  and  dyspeptic  disturbances  are 
not  marked  as  a  rule.     Jaundice  may  be  present.     Head's  zone. 

Enlarged  lymph-glands  can  hardly  be  mistaken,  as  there  is  the 
absence  of  gastric  symptoms;  no  gastric  findings,  as  in  carcinoma  of 
the  stomach ;  and  inflation  of  the  latter  organ  enables  a  differentiation. 

Growths  of  the  peritoneum  or  mesentery  are  more  diffuse  and 
rareh'  movable  on  respiration,  and  gastric  inflation  and  the  symp- 
toms enable  one  to  differentiate. 

Exudates  or  adhesions  give  none  of  the  symptoms  or  gastric 
findings  of  carcinoma. 

Duration  of  Carcinoma  of  the  Stomach. — Osier  reports  15 
cases  with  fatalit}^  under  three  months;  45,  under  a  year;  4  cases 
tAvo  years  or  over ;  i  case,  two  and  a  half  years.  The  general  average 
is  about  a  3'ear  to  a  year  and  a  half. 

Cases  involving  the  cardia  or  the  pylorus  are  more  rapid,  as 
subnitrition  occurs  more  quickly.  The  medullary  type  is  more 
quickly  fatal.     Complications  shorten  the  disease. 

It  is  interesting  to  learn,  however,  that  some  cases  of  inoperable 
carcinoma  of  the  stomach  improve  greatly  after  palliative  gastro- 
enterostomy. Eleven  such  cases  have  been  collected  from  Czernys'  ^ 
clinic,  in  which  the  patients  were  well  from  two  to  fourteen  years 
later. 

Prognosis. — This  has  been  considered  fatal,  though  recent 
results  are  more  favorable.  Surgery  has  relieved  conditions  tem- 
porarily and  prolonged  life,  while  medical  treatment  has  failed, 
though  it  has  helped  to  alleviate  suffering. 

Kocher  has  reported  i  case  in  which  the  patient  was  in  good 
health  five  and  a  half  years  after  resection  of  the  pylorus  for  car- 
cinoma; and  Wolfler  i  in  which  the  patient  was  well  for  five  years 
when  a  metastasis  occurred. 

Recently  a  few  isolated  cases  of  apparent  cure  have  been  reported. 
In  an  analysis  of  the  results  of  operative  treatment  of  gastric  cancer 
at  Braun's  Clinic  at  Gottingen,  Creite"  refers  to  i  case  in  which 
fourteen  years  after  resection  of  the  pylorus  for  carcinoma  the 
patient  was  in  perfect  health. 

Recently  more  favorable  results  have  been  reported.  Leriche^ 
has  collected  records  of  89  patients  on  whom  gastrectomy  was 
performed,  found  in  good  health  three  years  after  operation;  and  of 
these,  34  no  less  than  five  to  ten  years  after  operation. 

Out  of  79  cases  treated  by  gastrectomy,  Patterson*  collected 
33  (41.6  per  cent.)  who  were  free  from  recurrence  three  years  or  more 
after  operation. 

1  Wells,  "Resistance  to  Cancer,"  Jour.  Amer.  Med.  Assoc,  May  29,  1909. 

2  Journal  American  Medical  Association,  Aug.  24,  1907,  p.  723. 

3  Revue  de  Medecin,  Jan.,  1907. 

*  International  Medical  Annual,  p.  537,  190S. 


CANCER    OF   THE    STOMACH    (CARCINOMA    VENTRICULi)  26 1 

Deaver  shows  that  we  may  expect  10  to  15  per  cent,  to  be  cured 
by  radical  operation. 

According  to  Kausch/  Makkas  traced  92  of  MikuHcz's  patients 
operated  on  before  1902,  and  found  17,  or  14.3  per  cent.,  well  more 
than  three  years  after  operation.  Further  statistics  are  unnecessary. 
The  radical  operation,  gastrectomy,  evidently  affords  results  in  some 
cases. 

Schlatter  reported  in  1897  the  first  successful  case  of  total  extirpa- 
tion of  the  stomach,  with  survival  of  the  patient  for  a  considerable 
period.  Bernays,  of  St.  Louis,  and  others  have  reported  the  survival 
of  cases  for  some  time  after  operation.  The  operation  has  been 
generally  abandoned  and  we  find  that  the  so-called  gastrectomies 
are  generally  not  complete  removal. 

Treatment. — There  are  two  methods  of  treatment,  surgical  and 
medical,  of  which  the  only  hope  of  cure  lies  in  the  former,  medical 
treatment  being  only  justifiable  if  the  case  is  inoperable  or  refuses 
operation  or  as  an  adjunct  to  palliative  operation. 

Surgery. — Before  referring  to  the  radical  or  palliative  methods 
in  surgery,  I  desire  to  call  to  my  readers'  attention  the  necessity  of 
the  education,  not  so  much  of  the  patient  who  will  generally  consent, 
if  the  matter  is  placed  fairly  before  him,  but  of  the  physician  and  the 
specialist  in  gastric  diseases,  as  to  the  value  of  early  exploratory 
laparotomy  for  the  purpose  of  diagnosis. 

William  Mayo^  justly  remarks  that  in  an  early  exploratory  incision 
we  have  the  one  diagnostic  resource  which  is  reliable  and  which  must 
be  resorted  to  in  a  large  majority  of  cases  before  a  surgical  diagnosis 
can  be  made,  and  without  it  the  truth  is  but  slowly  established  at  the 
expense  of  progressive  hopeless  involvement.  It  can  be  safely 
accomplished  through  a  small  incision.  He  further  calls  to  our 
attention  that  the  chemic  findings  of  the  gastric  secretion  gain  in 
diagnostic  importance  with  the  progress  of  the  disease  and  become 
of  the  greatest  value  when  the  patient  is  in  a  hopeless  condition  and 
that  exploration  should  not  be  delayed  by  reason  of  the  inconclusive 
nature  of  the  results.  He  has  further  demonstrated  that  about 
60  per  cent,  of  cases  of  cancer  begin  in  the  pylorus  and  70  per  cent, 
in  the  pyloric  region,  and  that  the  early  diagnosis  of  cancer  depends 
in  a  great  measure  upon  the  introduction  of  the  mechanic  phenomena 
from  obstruction  at  the  pylorus.  It  is  the  interference  with  gastric 
motility  which  first  calls  the  patient's  attention  to  his  trouble  and 
not  the  presence  of  the  cancer  itself.  Moreover,  a  case  with  marked 
symptoms  of  cancer  of  the  stomach,  but  without  any  evidence 
of  pyloric  obstruction,  proves  on  exploration  to  be  the  victim  of 
advanced  and  hopeless  disease  of  the  body  of  the  organ,  in  which 
there  were  no  symptoms  during  the  operable  period.  The  presence 
of  a  tumor  does  not  demonstrate  inoperability,  as  a  small  movable 

'  International  Medical  Annual,  p.  5,^7,  1908. 
2  Annals  of  Surgery,  March,  1904. 


262 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


tumor  in  the  p3'loric  region  may  be  a  favorable  indication.  Limita- 
tion to  the  pyloric  end  and  mobility  are  the  important  factors,  also 
the  degree  of  lymphatic  infection. 

Pyloric  Stenosis  is  a  Surgical  Disease  Whether  it  is  Benign  or 
Malignant. — It  seems,  therefore,  especially  sound  doctrine  in  all 
cases  with  s^^mptoms  pointing  to  pyloric  stenosis,  in  patients  of 
forty  years  of  age  or  over,  to  perform  exploratory  laparotomy  to 
settle  the  type  of  stenosis  and  immediately  further  operation  of 


Fig.  136. — The  lymphatics  of  the  stomach  (Moynihan,  after  Cuneo). 

greater  or  lesser  extent,  the  character  depending  on  the  cause  of 
obstruction. 

In  elderly  persons,  previously  in  good  health,  with  gastric  symp- 
toms and  rapidly  developing  emaciation,  after  frequent  examinations 
both  of  the  patient  and  gastric  contents  for  several  weeks,  even  if  no 
definite  results  are  secured  by  analysis  and  no  tumor  be  detectable, 
exploratory  laparotomy  is  indicated.  vSome  patients,  of  course, 
will  not  consent  to  any  operation  until  even  palhative  operative 
procedure  is  too  late. 

I  have  seen  a  number  of  abdomens  opened  and  immediately 
closed  as  inoperable,  in  one  case  notably  the  entire  stomach  wall  being 


CANCER   OF   THE    STOMACH    (CARCINOMA    VENTRICULl) 


?63 


infiltrated.     If  the  medical  profession  would  recognize  the  value  of 
exploratory  incision,  I  believe  many  lives  could  be  saved. 

Radical  Operation. — Billroth,  in  1878,  was  the  first  to  prove  the 
possibihty  of  resection  of  the  pylorus  for  cancer,  but  it  has  been 
clearly  demonstrated  that  this  operation  is  insufficient.  Mikulicz 
has  pointed  out  that  on  the  lesser  curvature  the  blood  and  lymph- 
vessels  He  in  the  wall  of  the  stomach  itself,  and  that  it  is  necessary 


Fig.  137. — W.  J.  Mayo's  method  of  partial  gastrectomy  for  cancer  of  the 
stomach.  Ligation  of  gastrohepatic  omentum  and  superior  \'essels  in  such  manner 
as  to  leave  all  the  lymph-nodes  attached  to  the  part  of  the  stomach  to  be  excised; 
also  lines  of  division  of  duodenum  and  stomach:  a,  Mikulicz-Hartniann  line  (Fow- 
ler). 

in  every  case  of  pyloric  cancer  to  remove  all  the  lesser  curA^ature  to 
the  gastric  artery.  Cuneo  has  demonstrated  that  there  are  but  few 
lymph-glands  along  the  greater  curvature  and  that  these  are  con- 
fined to  the  pyloric  region. 

The  illustrations  (Figs.  136-138)  demonstrate  the  glandular 
relations,  the  correct  line  of  incision,  and  the  completed  operation. 

In  all  cases  of  pyloric  cancer  a  partial  gastrectomv  should  be  per- 
formed.    If  cancerous  metastases  or  luarked  adhesions  are  present, 


264 


DISEASES    OF   THE    STOMACH    AND    INTESTINES 


radical  operation  is  contra-indicated;  as  it  is  in  the  case  of  extreme 
debility  or  old  age. 

Mayo's  latest  statistics  show  11.45  P^r  cent,  mortality,  and 
Deaver's  11. 11  per  cent.  The  latter  has  tabulated  393  cases  by 
various  operators  with  an  average  26.5  per  cent,  fatality. 

Palliative  Operation. — This  should  be  performed  when  radical 
operation  cannot  be  carried  out,  to  prevent  death  from  starv'ation 


Fig.  138. 


-W.  J.  Mayo's  method  of  partial  gastrectomy  for  cancer  of  the  stom- 
ach.    Operation  completed  (Fowler). 


and  to  remove  the  irritating  effect  of  food  with  the  resulting  pain. 
The  operations  are: 

(a)  Gastrostomy  is  the  formation  of  a  fistulous  opening  into  the 
stomach;  indicated  in  cancerous  stenosis  of  the  cardia,  with  rapid 
loss  of  weight  and  severe  pain. 

(b)  Gastro-enterostomy  is  an  anastomosis  between  the  stomach  and 
small  intestine,  in  cancer  of  the  pylorus  with  stenosis ;  for  similar  reasons. 

These  operations  prolong  life  and  give  the  patient  considerable 
comfort,  and  there  is  often  temporary  increase  in  weight.  They  are 
less  severe  than  the  radical  operations  and  are  only  contra-indicated 


CANCER    OF    THE    STOMACH   (CARCINOMA    VENTRICULI)  265 

in  extreme  debility  or  great  age,  with  the  patient  in  such  condition 
that  fatahty  would  be  assured.  Gastrostomy  can  be  performed 
under  cocain  (local)  anesthesia  if  necessary.  I  have  already  referred 
to  the  fact  that  in  1 1  of  Czerny's  cases  the  patients  were  living  from 
three  to  fourteen  years  after  gastro-enterostomy. 

Medical  Treatment. — Diet. — The  first  important  feature  is  the 
endeavor  to  relieve  the  condition  of  subnutrition  and  to  give  the 
patient  food  which  he  will  most  easily  assimilate.  If  there  is  stric- 
ture of  the  pylorus  or  esophagus,  it  will  necessitate  the  use  of  liquid 
food  entirely,  or  mushes  in  addition,  if  there  is  less  severe  obstruction. 

If  the  cancer  involve  the  body  of  the  stomach  alone,  food  of  more 
solid  character  can  be  taken,  as  the  motor  functions  are  not  as 
greatly  interfered  with.  In  the  dietary  we  include  milk,  kumyss, 
matzoon,  bacillac,  farinaceous  food;  soups,  with  finely  divided 
vegetables,  such  as  pea,  bean,  and  potato;  broths,  gruels,  bouillon; 
raw  or  soft-boiled  eggs;  butter  in  plenty,  tea,  weak  coffee,  and 
cream;  crackers  softened  in  water  and  milk-toast. 

In  some  cases,  chicken,  squab,  scraped  meat,  sweetbread,  stale 
bread,  oysters,  fish,  etc.  Sanatogen  (flavored)  given  in  oij  (8.0)  doses 
up  to  I  ounce  a  day;  somatose,  Wyeth's  beef-juice,  Mosquera's  beef- 
jelly,  soluble  beef  peptonoids,  Armour's  extract  of  beef,  tropon,  and 
rare  beef -juice  are  all  of  value. 

I  have  employed  as  many  as  8  raw  eggs  a  day  beaten  up  in  milk, 
in  addition  to  other  foods.  They  possess  great  nutritive  value. 
Russell's  emulsion  of  mixed  fats  is  of  service.  Food  should  be  ad- 
ministered in  divided  small  meals,  four  to  eight  a  day.  The  calorie 
value  can  be  estimated,  but  the  chief  criterion  is  their  digestibility 
and  the  increase  in  the  patient's  weight,  which  should  be  carefully 
recorded.     Temporar}^  increase  in  weight  can  often  be  secured. 

X-rays. — There  have  been  various  claims  made  for  the  value  of 
the  x-ray  in  the  treatment  of  internal  cancer,  such  as  of  the  stomach 
or  intestines,  that  it  diminishes  the  size  of  the  growth  and  relieves 
pain.  I  have  seen  cases  in  which  the  pain  seemed  to  be  somewhat 
relieved,  but  never  any  permanent  results.  In  the  treatment  of  skin 
cancer  definite  or  even  curative  results  have  been  secured.  Beck's 
eventration  treatment  with  employment  of  the  .r-rays  is  described 
at  the  end  of  the  chapter.  Incidentally  Morton  has  recommended 
the  use  of  fluorescent  media  internally  in  connection  with  the  x-rays, 
but  Henry  Piffard  and  S.  Tousey  have  conclusively  exploded  his 
theory  and  shown  that  fluorescence  does  not  occur.  Direct  light 
rays  are  necessary. 

The  first  researches  with  the  internal  administration  and  dosage 
of  fluorescein  were  reported  by  me  in  connection  with  gastrodiaphany.^ 

Radium. — The  radium  treatment  for  cancer  of  the  stomach  and 
esophagus  was  first  introduced  by  Einhorn.^     He  employs  for  the 

1  Medical  News,  April  10,  1904. 

2  Medical  Record,  March  5,  1904. 


266  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

stomach  a  hard-rubber  capsule  that  can  be  unscrewed  and  which 
contains  a  glass  radium  flask  (Curie  20,000  strength).  To  the  rubber 
capsule  is  attached  a  silk  thread,  in  which  several  knots  are  tied, 
indicating  the  distance  from  the  lips  to  the  cardia  and  how  far  the 
capsule  lies  from  the  cardia.  The  capsule  is  introduced  Uke  his 
stomach-bucket.  The  thread  is  tied  to  the  lobe  of  the  ear  and  the 
capsule  left  in  the  stomach  for  one  hour. 

Binhorn  states  he  has  not  yet  formed  definite  conclusions  as  to 
results,  but  it  seems  to  be  of  palliative  benefit.  There  is  no  method 
of  determining  the  relation  of  the  capsule  to  the  tumor,  serious  burns 
have  resulted  from  prolonged  exposure  to  radium,  and  no  definite 
results  are  yet  reported.  I  would,  therefore,  not  recommend  the 
method. 

A  similar  instrument,  except  that  it  is  connected  to  a  thin  rubber 
tube  in  which  a  mandrin  is  slipped  for  the  purpose  of  introduction 


Fig.  139. — Einhorn's  radium  receptacle  for  treatment  of  cancerous  stenosis  of 
the  cardia:    Tubing,  mandrin,  and  receptacle. 

and  then  the  latter  removed,  has  been  devised  by  Einhorn  for  the 
treatment  of  mahgnant  esophageal  stricture  (Fig.  139). 

He  recommends  leaving  it  in  the  esophagus  from  half  an  hour  to 
an  hour,  and  claims  an  increase  in  the  permeability  of  the  stricture, 
less  pain,  and  increased  ability  in  swallowing.  As  in  this  case  the 
radium  can  be  directly  applied  and  some  definite  results  have  been 
secured,  the  method  might  be  of  value.  The  question  of  damage 
from  overexposure  must  be  carefully  considered.  The  method  is 
evidently  worthy  of  further  investigation. 

Drugs. — Sodium  lodid. — In  stricture  of  the  cardia,  Boas  has 
recommended  sodium  iodid,  gm.  2.0  to  3.0  (30-45  gr.),  in  divided  doses 
during  the  day,  and  claims  that  during  a  treatment  of  over  six 
months  the  patient  gained  a  little  in  weight  and  was  relieved  from 
some  of  the  symptoms.  Even  though  transient  improvement  occurs, 
it  is  worthy  of  trial  if  it  adds  to  the  patient's  comfort.  Admin- 
istration for  a  brief  period  would  decide  the  latter  question. 


CANCER   OF   THE    STOMACH    (CARCINOMA   VENTRICULl)  267 

Thiosinamin. — Sachs^  claims  to  have  been  successful  with 
thiosinamin  by  hypodermic  use  in  the  treatment  of  2  cases  of  pyloric 
stricture ;  and  Michaelis^  found  it  softened  an  esophageal  stricture 
and  enabled  him  to  dilate  it  with  bougies. 

Thiosinamin  (fibrolysin)  is  moderately  soluble  in  water,  soluble 
in  3  parts  of  alcohol,  and  readily  soluble  in  ether.  Hypodermic 
injection  of  fibrolysin  can  be  given  in  15  per  cent,  alcoholic,  or  10  per 
cent,   glycerin,   solution. 

The  average  dose  is  gr.  |  to  i|  (0.032-0.1  gm.).  Einhorn  advises 
its  use  by  mouth. 

It  is  worthy  of  trial  in  stenosis  of  the  esophagus  or  pylorus. 
The  following  is  useful: 

IJi.     Thiosinamin 0.5  (7^  gr.) ; 

Glycerini 6.0  (oiss.); 

SjTup.  cort.  aurant 20.0  ( o  v) ; 

Aq.  destU q.  s.  ad.  60.0  (oij). — M. 

Sig. — Teaspoonful  in  water  t.  i.  d. 

Arsenic  has  been  recommended,  Fowler's  solution,  3  to  5  drops 
(0.2-0.3)  daily;  or  sodium  arsenate,  gr.  3V  to  ^V  (0.002-0.0026), 
t.  i.  d.,  but  their  chief  value  is  combined  with  iron,  such  as  Gude's 
peptomangan,  or  iron  tropon,  to  combat  the  anemia. 

I^.     Blaud's  iron  pill  (fresh) gr.  v  (0.32) ; 

Sod.  arsen gr.  -50  (o-OOi3)- — M. 

One  pUl,  made  soft  with  honey,  is  an  excellent  combination  given  t.  i.  d. 

Condurango  was  first  recommended  by  Friedreich  in  1874  for  the 
treatment  of  cancer,  but  it  has  no  specific  action. 

Alone  or  combined  with  dilute  hydrochloric  acid  (suggested  by 
Ewald),  it  is  an  excellent  stomachic  to  improve  the  appetite,  and  at 
times  increase  of  weight  may  result. 

It  may  be  given  as  the  fluidextract  of  condurango,  15  to  20 
drops  (i. 0-1.3),  ill  water  t.  i.  d.,  with  or  without  dilute  hydrochloric 
acid,  half  an  hour  before  meals;  or  the  decoction  of  condurango  may 
be  employed: 

I^.     Decoction  condurango 20.0  to    25.0  gm. ; 

Water 200.0  to  250.0  cc. — M. 

Tablespoonful  t.  i.  d.  before  meals. 

Other  stomachics,  such  as  are  advised  in  chronic  gastritis,  are  of 
service : 

T^.     Acidi  hydroch.,  dilute ojj  (8.0); 

Tr.  nuc.  vomic __o  ij  (8.0) ; 

Comp.  tinct.  cinchona .' oSS  (16.0); 

Aq.  destil q.  s.  oiv  (125.0).— M. 

Dose,  one  to  two  teaspoonfuls  in  water  t.  i.  d.  before  meals. 

1  Ther.  d.  Gegenw.,  1907,  No.  i, 

2  Med.  Klin.,  1907,  No.  10. 


268  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

When  trypsin  treatment  is  employed,  the  acids  are  contra-indi- 
cated. 

Methylene-hlue. — Einhorn^  has  employed  methylene-blue  in 
capsules  once  or  twice  daily  for  some  years  past — gr.  3  (0.2  gm.)- 
In  I  case  the  tumor  appeared  smaller  for  a  time  and  did  not  increase 
in  size;  for  eight  months  the  patient  was  free  from  pain  and  lost  no 
further  weight.  Later  it  grew  again  and  the  case  succumbed.  He 
believes  it  exercises  a  beneficial  action  in  some  cases. 

A.  Jacobi-  advocates  its  use  in  inoperable  intra-abdominal  cancer, 
having  used  it  for  about  fifteen  years.  He  reports  cases  of  various 
types  and  claims  mitigation  of  symptoms,  prolongation  of  Hfe  for 
some  years  in  several  cases,  and  a  temporary  retrogression  of  the 
tumor.  He  does  not  claim  to  have  absolutely  cured  a  case.  He 
believes  that  exposure  to  sunlight  is  an  aid,  as  methylene-blue  is 
fluorescent. 

He  advocates  doses  (divided) ,  commencing  at  2  grains  a  day  and 
increasing  to  6  grains,  combining  belladonna,  and  suggests  the 
following : 

I^.     :\Iethylene-blue gr.  vj  (0.4) ; 

Ext.  belladonna gr.  |  (0.048) ; 

Arsen.  acid gr.  t^  (0.0065).— M. 

Di\'ide  into  foiir  pills. 

Sig. — One  t.  i.  d.  after  eating  and  at  bedtime. 

Methylene-bhte  treatment  may  be  tried  in  inoperable  cases  as 
a  palliative. 

Trypsin  Treatment. — For  the  theory  of  Beard,  on  which  he  bases 
his  so-called  trypsin  treatment,  I  refer  my  readers  to  his  various 
articles.  There  have  been  cases  of  apparent  cures  reported,  and 
others  of  complete  failure. 

Rice=*  reports  a  case  of  supposed  cancer  of  the  larynx  with  cure; 
while  Wm.  S.  Bainbridge-*  demonstrated  a  reported  cure  by  ]\Iorton 
to  be  an  absolute  failure. 

Shaw-:Mackenzie^  and  Carter*^  report  cures  in  apparently  hopeless 
cases,  while  Ball  and  Thomas'  report  unfavorably  in  1 1  cases.  There 
are  manv  other  reports  for  and  against  its  use.  Cleaves  beHeves 
this  treatment  to  be  justified,  noting  a  reUef  of  pain,  an  improvement 
in  metabolism,  and  improved  mental  condition.  She  described  a 
tr3'ptoglycogenic  reaction  as  occurring  from  its  use,  consisting  of  a 
moderate  leukocytosis  and  eosinophiUa. 

1  Deutsch.  med.  Wochenschr.,  i8qi.  No.  18. 

-Journal  Am.  Med.  Association,  Nov.  10,  1906. 

^Med.  Record,  Xov.  24,  1906. 

*  Xew  York  Med.  Journal,  March  2,  1907 

5  Med.  Press,  May  15,  1907. 

®  Med.  Press,  March  18,  1907. 

^  Archiv.  Middlesex  Hosp.,  vol.  ix,  in  Prac,  August,  1907. 


CANCER   OF   THE    STOMACH    (CARCINOMA    VENTRICUIj)  269 

Wm.  S.  Bainbridge,  of  New  York,  has  had  under  observation 
about  100  cases  undergoing  this  method  of  treatment,  which  are 
reported  in  the  Medical  Record  of  July  17,  1909. 

Space  will  only  allow  me  to  insert  a  small  portion  of  his  sum- 
mary in  which  he  deduced  the  following: 

1.  The  internal  medication  with  holadin  and  ox-gall  aids  digestion 
and  increases  elimination. 

2.  Aiding  digestion,  increasing  elimination  by  skin,  kidneys,  and 
bowels,  and  decreasing  local  absorption  are  the  most  important 
features  of  the  treatment. 

3.  The  regime  by  increasing  resistance  may  in  some  cases  de- 
crease the  rapidity  of  the  malignant  process. 

4.  Control  cases  given  sterile  water  plus  the  regime,  did  as  well  as 
those  on  the  full  enzyme  treatment. 

5.  Trypsin  injection  seems  in  some  cases  to  cause  disintegration 
of  (Hquefy)  the  cancerous  tissue  in  the  center  of  the  mass,  but  the 
periphery  continues  to  grow. 

6.  Amylopsin    injection    seems    to    diminish    cachexia    in    some 

cases. 

7.  In  a  small  percentage  of  cases  hemoglobin  improves  under 

trypsin  injection. 

8.  A  steady  increase  (6  to  12  per  cent.)  in  the  eosinophiles  oc- 
curred in  most  cases  during  the  trypsin  injections,  which  lessens 
under  amylopsin  injection.  There  was  no  increase  when  they  were 
given  by  mouth. 

9.  The  claims  for  eosinophilia  as  a  test  were  not  substantiated. 

10.  Beard's   enzyme  treatment   does   not   check   the   cancerous 

process. 

11.  It  does  not  prevent  metastases. 

12.  It  does  not  cure  cancer. 

'    The  author's  personal  observations  on  this  method  of  treatment 
will  be  shortly  described. 

"Trypsin' Treatment  for  Cancer."— With  sHght  changes,  I  have 
followed  Bainbridge's  modification  of  Beard's  method.  I  have  added 
secretin  to  the  treatment  to  stimulate  the  pancreas. 

Trypsin  {Special).     A  solution  of  double  strength  is  now  employed 

(Fairchild's).  .    . 

For  First  Mon//?-.— Begin  with  5  minims  (0.296  cc.)  deep  mjection 
daily  by  hypodermic.       Increase  5  minims  daily  up  to  35  to  45  minims 

daily. 

For  Second  Mow^/^.— Trypsin  one  day  5  minims  (0.296  cc). 
Amylopsin  next  day,  5  minims;  and  so  on  by  hypodermic. 
Run  each  up  with  daily  5  minims,  increase  up  to  35  to  45  mmims 

daily.  .   . 

For  Third  Mon//?.— Amylopsin  daily.  Commence  at  5  mmmis 
(0.296  cc.)  by  hypodermic.  Run  up  with  daily  5  minims  (0.296  cc.) ; 
increase  to  35  to  45  minims  daily. 


270  DISEASES    OF   the;    STOMACH   AND   INTESTINES 

If  symptoms  of  reaction,  temperature,  or  renal  disturbance, 
reduce  to  small  dose,  ITL  5  to  20  (0.296-1. 184  cc),  daily. 

If  local  irritation  from  injection,  use  ichthyol  and  ice-bag. 

Urine  should  be  examined  every  two  or  three  days.  Examination 
for  trypsin  in  the  urine  can  be  made,  as  described  by  Bainbridge. 

One  holadin  capsule  with  a  secretin  tablet,  gr.  i  (0.06),  should  be 
given  one  hour  t.  i.  d.  before  meals  throughout  treatment.  Ox-gall 
pepules,  dose,  2  each  night. 

Avoid  all  acids.     Give  as  little  salt  as  possible. 

Give  an  alkaline  mineral  water  one  and  a  half  hours  after  meals 
t.  i.  d. ;  can  employ  glass  of  Vichy  in  which  is  dissolved  J  teaspoonful 
of  soda  bicarbonate. 

Give  plenty  of  butter,  milk,  eggs  (raw),  nourishing  food,  etc. 

I  have  frequently  substituted  milk  of  magnesia,  5  j  to  5ij  (4.0-8.0), 
for  the  soda  bicarbonate  with  Vichy,  as  it  produces  less  gas  and  aids 
bowel  action. 

I  shall  refer  briefly  to  5  cases: 

Case  I. — At  the  Roosevelt  Hospital.  Carcinoma  of  the  anterior 
wall  of  the  stomach  (inoperable).  My  technic  for  the  first  week  was 
faulty,  but  was  followed  out  correctly  for  four  weeks,  during  which 
time  I  could  see  no  improvement,  but  no  apparent  retrogression. 
The  case  passed  out  of  my  hands. 

Case  II. — Same  hospital.  Carcinoma  of  the  bladder,  from  which 
a  villous  process  was  removed  and  examined,  confirming  the  diagnosis. 
The  patient  suffered  from  considerable  bladder  irritation.  After 
ten  days'  trypsin  injection,  this  condition  was  slightly  improved,  and 
several  small  fragments  of  the  villi  were  passed  in  the  urine. 

Beard  claims  a  disintegration  of  the  tumor.  Whether  the 
passage  of  this  material  was  a  coincidence  or  not,  I  am  not  prepared 
to  state.  At  the  end  of  three  weeks'  treatment  the  patient  had 
apparently  improved  slightly  and  insisted  on  leaving  the  hospital. 

These  cases  were  unsatisfactory,  as  further  obserA'ation  was 
impossible. 

Case  III. — This  patient  I  have  already  referred  to  as  one  of 
cancer  engrafted  on  an  ulcer.  The  patient,  aged  sixty-eight,  whose 
weight  two  years  ago  was  240  lbs.,  for  a  year  gave  the  history  of  ulcer 
of  the  stomach,  with  a  loss  of  weight  of  40  lbs.,  and  subsequent 
improvement  under  treatment  with  an  increase  of  10  lbs.  The 
pain  during  this  period  was  increased  on  eating,  and  he  had  free 
periods.     No  hemorrhage  as  far  as  I  can  learn. 

A  year  ago,  weight  210  lbs.,  he  began  to  grow  worse;  the  pain 
became  continuous  and  no  free  periods.  He  became  weak  and  more 
and  more  emaciated ;  anorexia,  no  vomiting. 

When  I  first  examined  him,  the  early  part  of  April,  1908,  he  was 
extremely  weak,  being  hardly  able  to  walk,  markedly  cachectic,  and 
anemic.  His  weight  had  fallen  from  210  to  149  lbs.  There  was  a 
hard  nodular  mass  to  the  left  of  the  median  line,  extending  from  the 


CANCER    OF   THE    STOMACH    (CARCINOMA   VENTRICUU)  27 1 

greater  curvature  upward  on  the  body  of  the  stomach.  This  was 
readily  palpable  and  showed  clearly  by  transillumination.  Motor 
insufficiency  was  slight. 

The  gastric  findings  have  always  shown  a  total  acidity  varying 
from  90+  to  100+  and  free  HCl  65+  to  70+  (hyperchlorhydria) ; 
moderate  leukocytosis  12,000,  and  a  slight  increase  in  the  eosinophiles. 

I  have  already  referred  to  the  fact  that  hyperchlorhydria  may  be 
present  in  cancer  and  persist  even  to  the  time  of  death.  The  patient 
suffered  from  chronic  nephritis. 

During  the  first  month,  under  trypsin  treatment,  there  was 
slight  increase  of  leukocytosis  and  eosinophilia  up  to  9  to  11  per 
cent.,  averaging  about  9  per  cent. 

In  the  second  month,  with  trypsin  alternating  with  amylopsin, 
the  eosinophilia  slightly  diminished  to  about  8  per  cent. 

The  patient,  midway  in  the  third  month,  with  amylopsin  alone 
injected,  eosinophilia  was  7  per  cent. 

Holadin,  alkalis,  etc.,  continued  as  usual.  No  opiates  and  no 
alcohol  or  heart  stimulants  have  been  employed. 

The  patient  averages  8  raw  eggs  a  day,  milk,  gruels,  a  moderate 
amount  of  bread  with  plenty  of  butter,  sanatogen  oj  daily,  etc. 

The  weight  increased  to  160  lbs.,  a  gain  of  1 1  lbs.,  the  pain,  which 
was  formerly  continuous,  occurred  only  occasionally  at  night.  As 
nothing  was  given  for  the  pain,  I  am  forced  to  attribute  the  improve- 
ment to  the  specific  treatment.  The  patient's  strength,  appearance, 
and  mental  condition  were  greatly  improved,  and  he  walked  daily 
in  the  park.  The  growth  did  not  increase  in  size  and,  in  fact,  slightly 
diminished.    The  forced  feeding  undoubtedly  improved  the  nutrition. 

Treatment  for  hyperchlorhydria  did  not  relieve  the  continuous 
pain,  as  it  was  carried  out  for  a  week  before  the  trypsin  treatment 
was  begun  with  no  results.  A  second  course  of  trypsin  treatment 
was  administered,  and  the  patient,  on  leaving  at  the  end  of  August, 
weighed  169  lbs.,  and  was  in  quite  good  physical  condition,  being  able 
to  exercise  and  having  only  occasional  pain. 

I  can  substantiate,  in  this  case  at  least,  the  statements  of  Cleaves 
as  to  leukocytosis,  eosinophilia,  the  relief  of  pain,  and  the  mental 
improvement.  The  tumor,  apparently,  diminished  considerably  in 
size,  but  did  not  disappear.  The  patient  returned  to  work  and  died 
of  pneumonia  two  months  later. 

I  could  not  attribute  the  improvement  in  nutrition  in  this  case 
to  the  trypsin,  as,  in  view  of  the  location  of  the  growth,  the  motor 
functions  were  excellent. 

Case  IV. — This  patient,  aged  thirty-eight,  male,  was  a  steady 
drinker.  Two  years  before  he  had  an  attack  apparently  of  gastric 
ulcer  with  several  hemorrhages;  then  was  in  fair  condition  for  some 
months  with  slight  gastric  symptoms.  Six  months  previous  to 
admission  to  the  hospital  he  began  to  lose  weight  and  strength, 
the  gastric  symptoms  became  more  severe,  and  he  began  later  to 


272  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

vomit.  His  weight  at  the  commencement  of  his  last  attack  was 
190  lbs.  When  I  saw  him  in  October,  1908,  he  weighed  120  lbs., 
anemia  and  cachexia  were  marked,  vomiting  six  to  eight  times  daily, 
ectasia  with  the  lower  border  of  the  stomach  three  fingers  below  the 
umbilicus,  a  distinct  hard  mass  palpable  in  the  epigastrium,  blood  in 
the  vomitus  and  stool.  The  pulse  was  very  feeble,  hardly  detectable, 
and  he  was  only  able  to  walk  with  the  aid  of  support.  He  was  at 
once  admitted  to  the  Red  Cross  Hospital,  where  the  visiting  surgeon 
and  one  of  the  physicians  in  consultation  with  me  agreed  that  even 
palliative  gastro-enterostomy  could  not  be  risked.  Lavage  was  per- 
formed twice  each  day,  and  forced  feeding  with  8  to  10  raw  eggs  daily, 
sanatogen,  oj  (64.0),  in  divided  doses;  iron  tropin,  5j  (4.0)  t.  i.  d. ;  pep- 
tonized milk  in  divided  doses,  i  quart  (liter)  in  all,  butter,  broths, 
gruels,  etc.  The  patient  only  vomited  twice  after  lavage  was  begun. 
Rose's  belt  was  applied  to  elevate  the  stomach,  and  after  each  feeding 
the  patient  was  turned  on  the  right  side,  where  he  remained  for  half 
an  hour  to  aid  in  emptying  the  organ.  Olive  oil,  oij  (60.0),  was  also 
given  twice  daily  for  the  same  purpose. 

On  admission  October,  1908:  Gastric  analysis,  free  HCl  absent; 
lactic  acid,  large  amount;  Boas-Oppler;  blood. 

Blood. — Slight  leukocytosis,  11,000;  red  cells,  3,200,000;  hemo- 
globin diminished;  eosinophilia  slight;  nephritis,  probably  due  to  al- 
coholism. Trypsin  injections  were  given  for  a  month,  then  for  the 
second  month  trypsin  alternating  with  amylopsin. 

Leukoc3^tosis  slightly  increased;  eosinophils,  9  to  11  per  cent, 
during  trypsin  injection,  7  to  8  per  cent,  during  the  combination. 
There  was  a  gain  of  i  ,000,000  red  cells  in  the  course  of  the  two  months. 
At  the  end  of  this  period  a  gain  in  weight  of  20  lbs.,  the  patient  felt 
quite  strong,  and  was  able  to  walk  about  without  assistance.  His 
pulse  was  excellent. 

Operation  was  then  performed  (gastro-enterostomy)  on  account 
of  adherency  of  tumor  and  of  many  glandular  enlargements. 

Subsequent  to  operation,  holadin,  ox-gall  pepules,  and  secretin 
with  alkalis  were  continued,  but  no  further  injections.  Forced 
feeding  and  tonics  were  resumed  as  soon  as  possible.  The  patient 
remained  three  months  in  the  hospital  after  operation,  gaining  in  all 
38  lbs.  Six  weeks  later  he  reported  a  further  gain  of  2  lbs.  He  con- 
tinued the  internal  medication  with  holadin,  secretin,  etc.  It  is 
now  nearly  a  year^  since  he  entered  the  hospital  in  extremis,  and  the 
condition  is  the  same  as  when  he  left  the  institution.  There  was  no 
disappearance  of  the  tumor,  though  the  growth  seemed  slightly  smaller 
after  the  injections. 

Case   V. — Male,  aged  fifty-six,  history  of  gastric  symptoms  of 

six  months'  duration,  original  weight  155  lbs.     On  admission  to  Red 

Cross  Hospital  weight  1 20  lbs.    Occasional  vomiting,  anemia,  cachexia. 

1  This  patient  recently  began  to  drink  and  neglect  himself  and  has  lost  con- 
siderable weight,  is  anemic  and  cachectic,  but  no  vomiting.  Under  resumption 
of  forced  feeding  and  tonics  he  is  improving. 


CANCER   OF   THE    STOMACH    (CARCINOMA    VENTRICUu)  273 

Gastric  analysis,  free  HCl  absent ;  lactic  acid  present ;  Boas-Oppler ; 
no  blood.  Leukocytosis  slight ;  eosinophiles  slight  increase.  Ectasia 
to  one  finger  below  umbiHcus.  Tumor  palpable  in  epigastrium.  Pulse 
quite  good.  Immediate  operation  was  advised.  The  growth  was  not 
large,  but  there  was  considerable  glandular  involvement  and  some 
nodules  on  the  liver.  Palliative  gastro-enterostomy  was  performed. 
On  the  fourth  day  nutritive  enemata  were  no  longer  retained  and 
the  patient  was  given  strained  broths,  barley-water,  white  of  egg, 
etc.,  by  mouth;  later,  peptonized  milk,  and  as  rapidly  ac  possible 
forced  feeding  was  begun.  Two  weeks  after  the  operation  trypsin 
treatment  was  commenced. 

The  patient  ultimately  gained  ^o  pounds  in  weight. 

There  was  no  change  in  the  tumor,  it  apparently  remaining  the 
same  size.     Seven  months  later  conditions  were  the  same.^ 

There  is  no  excuse  for  abscess  formation  during  the  trypsin  treat- 
ment if  proper  aseptic  precautions  are  taken.  I  have  always  ap- 
plied a  5  per  cent,  ichthyol  ointment  dressing  over  each  fresh  punc- 
ture for  twenty-four  hours  thereafter  as  an  extra  precaution  and 
have  never  had  an  abscess.  The  iliolumbar  region,  between  the 
twelfth  rib  and  the  crest  of  the  ilium,  is  the  point  of  selection  for  the 
injections,  alternating  from  one  side  to  the  other. 

It  is  not  necessary  to  employ  a  special  syringe  and  pain  is  avoided 
by  using  the  ordinary  hypodermic  as  follows :  decant  from  the  ampule 
the  required  amount  of  trypsin  or  amylopsin  into  a  sterile  glass. 
If,  for  example,  40  drops  are  to  be  injected,  fill  the  syringe  with  20 
drops,  and  at  the  end  of  the  injection  unscrew  the  barrel,  leaving 
the  needle  in  situ.  The  syringe  is  then  refilled,  screwed  on  to  the 
needle  at  the  site  of  puncture,  and  the  residue  injected. 

Deductions. — The  mental  effect  on  the  patient  is  excellent;  pain 
was  relieved  in  one  case:  eosinophilia  was  markedly  increased  by  the 
trypsin  injections,  less  by  the  alternating  injections,  and  some  in- 
crease by  the  amylopsin  injections.  I  believe  this  feature  shows 
increased  body-resistance,  just  as  the  presence  of  eosinophilia  in  t}"- 
phoid  is  a  favorable  symptom.  In  2  cases  the  growth  seemed  to 
decrease  in  size.  There  was  no  disappearance  of  the  tutnor  in  any  case. 
We  must  remember  that  the  palliative  gastro-enterostomy  relieves 
irritation,  and  in  some  cases  the  growth  becomes  quiescent  for  a  long 
period.  The  forced  feeding  improves  nutrition.  This  should  be  con- 
tinued indefinitely,  together  with  the  holadin,  secretin,  ox-gall,  iron, 
and  arsenic.  I  consider  trypsin  treatment  justifiable  in  inoperable 
cases  and  in  those  on  whom  palliative  operation  has  been  performed, 
as  it  seems  to  produce  some  benefit  as  an  adjunct.  Further  investi- 
gations should  be  carried  on. 

Thymus. — F.  Gwyer^  reports  the  use  of  dried  and  powdered 
thymus  of  the  calf  in  doses  of  oj  to  iv  (4.0-16.0)  three  or  four  times 

1- This  patient,  Nov.  27,  1909,  is  engaged  in  active  business. 
2  Annals  of  Surgery,  July,  1907. 

18 


274  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

a  day.  He  claims  diminution  of  pain,  reduction  of  size  of  growth, 
improved  digestion,  and  diminution  or  arrest  of  the  growth.  EHmi- 
nation  is  through  the  secretory  organs  and  considerable  reaction 
occurs,  so  it  cannot  be  used  for  over  three  weeks.  There  is  a  certain 
amount  of  danger  from  auto -intoxication  and  the  method  is  still 
under  experiment,  so  that  I  would  not  advise  its  employment. 

Coley's  fluid  (erysipelas  toxin)  might  be  tried,  though  the  results 
have  been  more  favorable  in  inoperable  sarcoma  and  rarely  in  car- 
cinoma.    I  do  not  advocate  its  use. 

Bier  has  reported  some  improvement  in  superficial  cancer  by 
injection  of  heterologous  blood  of  a  pig  (lo  to  20  cc.  at  a  dose) ;  and 
Leyden  and  Bergel  have  experimented  on  animals  suffering  from 
cancer  with  the  injection  of  liver  extracts,  but  these  methods  are  also 
experimental.^ 

Vomiting  and  Ectasia. — Systematic  lavage  is  indicated  for  these 
conditions  with  normal  saline  solution  or  milk  of  magnesia,  §j  to  oij 
(30.0-60.0)  to  the  quart  (liter)  of  water;  if  marked  fermentation, 
resorcin,  gr.  xv  (i-o),  can  be  added;  or  glycothymolin  or  listerin, 
3j  (4.0)   to  Oj   (500  cc.)  of  water,  etc. 

Hemorrhage. — This  is  usually  not  severe.  Morphin,  gr.  ^  (0.016), 
by  hypodermic;  the  ice-bag;  gelatin,  5  to  10  per  cent,  solution,  by 
mouth,  3ij  to  ^ss  (8.0-16.0),  every  one  to  two  hours  for  twelve  hours 
are  useful;  also  hypodermics  of  ernutin,  "Hlv  (0.296  cc),  or  ergot 
fluidextract,  and  the  methods  described  for  hemorrhage  under 
Gastric  Ulcer, 

Tremoliere's  Solution. — Gelatin  (5  per  cent,  solution)  with 
calcium  chlorid  (2  per  cent.)  therein.  Dose,  Sss  to  §j  (30.0-60.0)  by 
mouth,  repeated  every  four  hours,  is  of  value.  There  are  not  the 
indications  to  relieve  hyperchlorhydria  as  in  ulcer,  so  rectal  feeding 
may  be  instituted  for  twenty-four  hours  or  longer.  The  ice-bag 
should  be  kept  on  for  twenty-four  hours.  Gelatin  thereafter  (3 
per  cent,  solution)  should  be  used  for  several  days,  in  divided 
doses  up  to  5xij  (375  cc.)  in  twenty-four  hours.  White  of  egg  is  of 
value  on  the  following  day,  and  then  fluid  diet,  and  a  gradual 
return  to  the  usual  feeding. 

Pain. — ^The  application  of  heat  b}^  the  hot-water  bag  or  hot 
poultices  is  indicated.  Boas  recommends  3  to  5  drops  of  chloroform 
on  ice  to  be  given  occasionally.  Chloral  hydrate,  3  to  5  gr.  (0.2-0.3) 
in  water,  has  been  recommended  by  Ewald,  but  if  the  patient  be  very 
weak  it  is  a  dangerous  remedy.  Lavage  will  often  relieve  acute 
attacks,  especially  if  stenosis  with  dilatation  are  present. 

Orthoform  or,  preferably,  orthoform  hydrochlorid,  which  is 
more  soluble  in  water,  can  be  given  t.  i.  d.,  gr.  v  to  viiss  (0.3-0.5). 

Tincture  belladonna,  Hlx  (0.66)  t.  i.  d.,  or  extract  belladonna, 
gr.  ^  (0.022)  t.  i.  d.,  are  valuable.       Heat,  belladonna,  lavage,  and 

1  Cancer  vaccine  (neoformans)  has  been  recommended  for  injection,  but 
further  investigation  is  required  as  to  its  value. 


OTHER   TUMORS    OF   THE    STOMACH  275 

orthoform  should  first  be  tried.  If  they  fail,  it  may  be  necessary 
to  employ  codein,  preferably,  gr.  ^  to  3  (0.008-0.032)  by  mouth,  or 
gr.  I  (0.016)  by  hypodermic;  or,  as  a  last  resort,  morphin,  gr.  ^  to 
I  (0.008-0.016).     In  terminal  cases  the  opiates  are  indicated. 

Bowels. — For  constipation,  enemata  of  soap  and  water,  with  or 
without  olive  oil,  bowel  irrigation,  injection  of  olive  oil  (Iviij  to  Oj 
(250  CC.-500  cc.)  at  night,  to  be  retained,  rhubarb  pills,  the  cascara 
preparations,  aloes  and  belladonna  compound  pills,  purgen  or  phe- 
nolax  tablets,  and  compound  licorice  powder,  are  all  of  service. 

For  diarrhea,  the  bismuth  preparations,  subnitrate  of  bismuth, 
i.o  to  2.0  (gr.  xv-3ss),  several  times  a  day;  or  bismuth  salicylate, 
gr.  V  to  X  (0.32-0.64),  three  or  four  times  a  day;  or  subgallate  of 
bismuth,  the  same  dose;  or  subcarb.  bismuth,  i.o  (15  gr.),  three  or 
four  times  a  day,  are  of  value.  Chalk  mixture  or  comp.  tinct.  catechu 
or  kino,  in  3ss  (2.0)  doses,  may  be  combined;  or  at  times  tinct,  opii, 
1Ux  (0.892),  or  tinct,  opii  camphorat.,  Tllxv  to  xxx  (0.888-1.7776 
cc),  may  be  required  in  addition. 

Stenosis  of  the  Cardia. — This  may  require  cautious  dilatation, 
preferably  with  soft  tubes,  if  possible. 

In  conclusion,  I  desire  to  refer  to  an  interesting  communication 
by  Carl  Beck.^  In  several  cases  of  intra-abdominal  cancer  one 
(notably  of  the  pylorus)  incision  was  made  over  the  growth,  and  the 
latter  stitched  to  the  skin,  making  it  practically  cutaneous.  The 
x-TSLys  were  then  applied,  with  apparent  disappearance  of  the  growth 
in  several  cases.  In  some  the  wounds  were  allowed  to  granulate, 
and  in  others  the  stomach  was  reduced  after  separation  of  adhesions. 
In  some  of  the  cases  the  report  was  certainly  favorable.  It  would 
seem  that  in  cases  of  cancer  of  the  stomach  in  which  extirpation  is 
impossible,  gastro-enterostomy  combined  with  Beck's  treatment, 
just  described,  the  use  of  trypsin,  and  forced  feeding  to  improve  the 
resisting  power  of  the  patient,  might  give  the  best  results. 

OTHER  TUMORS  OF  THE  STOMACH 

Other  tumors  of  the  stomach  (excepting  carcinoma)  are  com- 
paratively rare.  Sarcomata,  lipomatoma,  fibromata,  and  myomata 
have  been  found,  and  also  polypoid  excrescences  due  to  proliferation 
of  the  glands. 

Sarcoma  is  the  most  common  of  these  varieties,  and  may  be 
primary  or  secondary. 

Primary  myosarcoma  and  fibrosarcoma  are  generally  in  the  form 
of  circumscribed  nodules  in  the  stomach  wall,  while  lymphosarcoma  is 
flatter  and  infiltrates. 

The  tumors  vary  in  size  and  form  and  are  situated  generally  on 
the  greater  curvature.     Metastases  are  frequent. 

Primary  Ivmphosarcoma  appears  most  frequently  between  t  wenty 

1  On  External  Rontgen  Treatment  of  Internal  Structures  (Eventration 
Treatment),  New  York  Med.  Journal,  March  27,  1909. 


276  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

and  thirty-five  years  of  age,  while  the  other  types  occur  more  fre- 
quently in  older  subjects. 

Symptoms  of  Sarcoma  of  the  Stomach. — These  appear  somewhat 
insidiously,  in  some  cases  gradual  emaciation  being  first  noted;  the 
stomach  symptoms  are  practically  the  same  as  in  carcinoma :  loss  of 
appetite,  sour  belching,  a  feeling  of  pressure  and  fulness,  disagreeable 
taste,  pain,  vomiting,  and,  finally,  coffee-grounds  in  the  vomitus. 
Dilatation  of  the  stomach,  if  pyloric  involvement  and  tetany  have 
been  observed  in  this  type  of  case. 

Gastric  Analysis. — Absence  of  free  hydrochloric  acid;  presence  of 
lactic  acid;  Boas-Oppler  bacilH  are  frequently  present. 

In  effect,  we  may  say  the  gastric  findings  and  symptoms  are 
similar  to  carcinoma. 

The  methods  of  physical  examination  are  the  same  as  in  carcinoma 
of  the  stomach. 

Average  duration  is  from  one  to  one  and  a  half  years.  Schle- 
singer  and  Kundrat  have  shown  that  certain  factors  may  be  utiHzed 
for  the  purpose  of  differential  diagnosis. 

Metastases  of  the  skin  are  more  frequent  with  sarcoma,  and 
excision,  with  examination  of  a  cutaneous  nodule,  when  such  is 
present,  will  afford  positive  information.  Metastases  in  the  intestine 
occur  more  frequently  with  lymphosarcoma,  and  these  do  not  pro- 
duce stricture,  but  dilatation;  while  carcinoma  causes  stenosis  of 
the  gut. 

The  lymph-glands  are  more  swollen  in  sarcoma. 

The  spleen  is  also  swollen  in  sarcoma,  not  so  in  carcinoma. 

The  tongue  folhcles  are  at  times  swollen  and  tumefied  and  infil- 
tration of  the  tongue  may  occur;  there  is  a  symmetric  arrangement 
of  the  ridges,  nodules,  and  papillae. 

Harlow  Brooks  beUeves  the  growth  usually  appears  at  the  lesser 
curvature  of  the  stomach,  though  it  may  occur  in  other  regions. 
It  may  be  multiple. 

Treatment. — Early  surgical  operation,  if  possible,  the  indication 
being  the  same  as  in  carcinoma. 

Lavage  is  indicated  if  dilatation  be  present.  Coley's  fluid  (ery- 
sipelas toxin)  has  proved  of  value,  especially  in  some  cases  of  sar- 
coma, and  should  be  tried  in  inoperable  cases.  Severe  reaction  and 
renal  disturbance  may  follow  its  use,  so  it  should  be  employed  with 
caution. 

The  diet  should  be  the  same  as  in  carcinoma,  and  the  use  of 
stomachics. 

Arsenic  (Fowler's  solution),  beginning  at  TTLv  (0.296)  and  grad- 
ually increasing  to  Ttlxv  (0.888)  t.  i.  d.,  can  be  tried  in  lymphosarcoma. 

Benign  Tumors. — Benign  tumors  of  the  stomach  are  a  rarity  and 
practically  impossible  to  differentiate  in  many  cases.  The  cachexia 
and  gastric  findings  of  malignancy  would  be  absent. 

With  benign  pyloric  stenosis,  a^  tumor  (thickening)  is  palpable 


FOREIGN    BODIES    IN    THE    STOMACH  277 

in  some  cases,  but  the  s^^mptoms  would  be  of  benign  stenosis,  cachexia 
absent,  and  usually  hyperacid  gastric  contents. 

Occasionally  a  small  tumor  has  been  noted  lying  on  the  greater 
curvature,  due  to  enlargement  of  a  lymph-gland  secondary  to  an 
inflamed  ulcer. 

APPARENT  TUMORS  OF  THE  STOMACH 

Einhorn^  has  described  cases  of  apparent  tumors  of  the  abdomen 
which  have  been  mistaken  for  tumors  of  the  stomach,  notably, 
prolapse  of  the  left  lobe  of  the  liver,  exposure  of  the  aorta  (abdominal) , 
thickening  of  the  abdominal  muscles  (recti),  and  adhesions  of  the 
lesser  curvature.  Enteroptosis  of  a  considerable  degree  is  usually 
associated  with  the  first  two  conditions  and  the  history  is  a  long  one. 
Pulsation  of  the  aorta  may  be  mistaken  for  aneurism.  Cirrhosis  of 
left  lobe  of  liver  may  simulate  cancer  of  the  stomach  on  palpation. 
The  gastric  analysis  and  other  symptoms  will  differentiate  these 
conditions.  With  gastroptosis  the  pancreas  has  been  palpated  and 
mistaken  for  gastric  tumor.  In  some  cases  a  transient  tumor  in 
the  region  of  the  stomach  dependent  evidently  on  spasm,  as  from 
ulcer,  has  been  noted.     Schnitzler-  observed  such  a  case. 

Thickening  of  the  recti  is  diagnosed  as  follows:  The  thighs  and 
knees  are  well  flexed,  and  the  head  and  shoulders  elevated  so  as  to 
produce  marked  relaxation  of  the  abdominal  muscles.  It  will  then 
be  possible  to  slip  the  finger-tips  beneath  the  edges  of  the  relaxed 
and  thickened  rectus  muscle. 

FOREIGN  BODIES  IN  THE  STOMACH 

These  may  be  swallowed  occasionally  or  purposely,  or  may  be 
gradually  deposited  in  the  stomach. 

Among  such  articles  are  pins,  needles,  scarf-pins,  knives,  spoons, 
forks,  artificial  teeth,  glass,  hooks,  pens,  buttons,  balls  of  hair,  bits 
of  iron,  nails,  lead,  wood,  and  even  the  stomach-tube.  Lunatics, 
idiots,  and  young  children  frequently  swallow  foreign  bodies,  as  do 
trick  knife-swallowers.  Cases  have  been  reported  of  patients  who 
have  worked  with  an  alcoholic  solution  of  shellac,  and  who  had 
swallowed  small  quantities  daily,  with  the  ultimate  formation  of 
stones  in  the  stomach.  Sarcinae  ventriculi  have  also  accumulated 
in  large  numbers  and  formed  a  tumor. 

There  may  be  local  disturbances  of  severe  type  and  vomiting,  or 
if  damage  be  done  to  the  mucous  membrane,  then  hemorrhage. 
On  the  other  hand,  there  may  be  no  disturbances  at  all  and  the 
foreign  body,  especially  if  of  small  size  and  smooth,  may  be  evacuated 
from  the  bowels.  The  history  of  the  case  will  generally  give  us 
information.  If  the  tumor  be  of  sufficient  size  and  very  movable, 
it  can  be  at  times  appreciated  by  palpation. 

1  Medical  Record,  Nov.  24,  1900. 

2  Centralblatt  f.  Chir.,  vSept.  3,  1898. 


278  DISEASES   OF  THE   STOMACH  AND  INTESTINES 

The  :x;-rays  will  give  information  as  to  its  presence. 

Treatment. — The  use  of  an  emetic  is  objectionable,  as  a  rule, 
unless  the  foreign  body  is  extremely  small  and  smooth.  Personally, 
I  never  employ  it.  Mayou  has  recommended  the  use  of  an  electro- 
magnet inserted  in  a  stomach-tube,  there  being  sufificient  space  at 
the  end  of  the  tube  to  draw  in  a  small  metallic  object  which  can  be 
located  by  the  x-rays. 

Under  usual  conditions,  the  administration  of  constipating  food, 
potatoes,  rice,  and  the  soft  part  of  bread,  and  keeping  the  bowels 
costive  for  several  days,  so  as  to  form  a  protective  mass  about  the 
foreign  body,  is  the  best  method  of  treatment.  It  is  an  error  to 
immediately  administer  a  catharic,  as  damage  is  done  to  the  intestinal 
canal  if  there  be  any  sharp  edges  to  the  object.  Complications,  such 
as  perforation  or  inflammatory  adhesions,  are  liable  to  occur  if  it 
be  of  any  size.  Intestinal  obstruction  may  even  result.  If  the 
body  is  of  large  size  or  serious  symptoms  ensue,  early  gastrotomy 
is  indicated. 


CHAPTER  XIV 
FUNCTIONAL  DISEASES  OF  THE  STOMACH 

Under  functional  diseases  of  the  stomach  we  may  classify  those 
affections  in  which  either  the  secretory  or  motor  functions  of  the 
stomach  are  at  fault.  Anatomic  lesions  are  present  in  some  cases 
and  are  absent  in  others. 

The  principal  symptoms  are  due  to  the  disorders  of  secretion 
or  motility.  Among  these  we  classify  hyperacidity  (hyperchlor- 
hydria),  hypersecretion  (gastrosuccorrhea) ,  atony  of  the  stomach, 
dilatation  of  the  stomach,  and  achylia  gastrica. 

Many  cases  of  hyperacidity  and  of  hypersecretion  are  pure 
secretory  neuroses,  atony  may  also  result  from  nervous  disorders; 
but  there  are  other  causes  for  these  conditions. 

When  there  is  dilatation  due  to  stenosis  of  the  pylorus,  as  from 
maUgnant  tumor,  the  symptoms  are  due  to  the  cancer  and  also  to 
the  relative  motor  insufficiency.  It  is  difficult,  therefore,  to  place 
any  special  disease  of  the  stomach  under  a  pure  classification,  owing 
to  the  diverse  etiology.  With  achylia  gastrica  we  have  the  loss  of 
secretory  functions  of  the  stomach,  and  it  may  be  classified  under 
functional  diseases.  It  is  produced  either  by  nervous  influences  or 
by  anatomic  changes  in  the  gastric  mucous  membrane.  As  in  rhany 
cases  organic  changes  are  present,  I  judged  it  advisable  to  devote  to 
it  a  separate  chapter. 

HYPERACIDITY  (HYPERCHLORHYDRIA) 

{Synonyms. — Hyperaciditas  Hydrochlorica;  Superacidity.) 

~  The  term  "hyperchlorhydria"  should  be  used  to  designate  an 
increased  secretion  of  gastric  juice  or,  more  correctly,  of  hydrochloric 
acid,  during  the  period  of  digestion;  that  is,  an  overproduction  of 
this  acid.  Under  normal  conditions  the  free  hydrochloric  acid 
fluctuates  in  the  stomach  within  certain  limits,  thus : 

Free  HCl  averages  between  25+  and  50  +  ,  or  about  .1  to  .2  per 
cent.,  and  the  total  acidity  from  40  +  to  65  +  ,  or  .  146  to  .237  per  cent. 

We  speak  of  hyperchlorhydria  when  not  only  the  total  acidity  is 
higher  than  normal,  but  when  the  excess  of  free  HCl  is  above  normal. 
It  is  not  "sufficient  to  merely  test  for  the  total  acidity,  as  it  may  be 
increased  by  organic  acids.  The  free  HCl  should  be  determined 
quantitatively. 

279 


28o  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

We  might  place  a  total  acidity  of  70  + ,  of  which  the  greater  part 
consists  of  free  hydrochloric  acid,  on  the  dividing  line.  A  patient 
with  such  a  degree  of  acidity  and  complaining  of  clinical  symptoms 
may  be  considered  a  case  of  hyperchlorhydria. 

A  total  acidity  of  100  to  120,  with  free  HCl,  80+  to  90+ ,  is  quite 
common,  and  much  greater  degrees  of  hyperchlorhydria  have  been 
observed. 

We  must  remember  that  individual  idiosyncrasies  exist  as  to 
the  susceptibility  to  free  HCl.  We  occasionally  find  patients  with 
a  total  acidity  of  100  +  ,  the  greater  part  of  which  is  free  HCl,  who 
have  no  subjective  disturbances  whatever  and  never  suffer  any 
discomfort. 

On  the  other  hand,  I  have  at  present  a  patient  under  treatment 
with  a  total  acidity  of  60  +  and  free  HCl  40  + ,  who  has  all  the  symp- 
toms of  hyperchlorhydria. 

Frequency. — It  was  formerly  thought  that  in  most  diseases  of 
the  stomach  the  gastric  secretion  was  deficient,  but  it  has  been 
demonstrated  that  the  gastric  juice  is  increased  in  about  one-half 
the  cases. 

One  does  not  see  so  many  cases  of  hyperchlorhydria  in  hospital 
practice,  except  in  connection  wdth  gastric  ulcer,  since  the  symptoms 
rarely  become  so  severe  as  to  require  hospital  treatment.  As  a 
concomitant  of  chlorosis  it  is  frequently  found.  The  gastric  analysis 
in  these  cases  is  often  neglected.  Moreover,  the  general  practitioner 
rarely  examines  the  gastric  contents  in  cases  which  present  the 
symptoms  of  hyperacidity.  It  is,  therefore,  difficult  to  secure 
statistics  as  to  its  frequency.  . 

Einhorn  reports  a  trifle  more  than  one-half  his  patients  to  be 
sufferers  from  hyperchlorhydria.  Records  of  my  private  patients 
show  that  about  50  per  cent,  come  to  me  for  treatment  for  this 
condition. 

Etiology. — No  age  is  exempt.  It  is  met  with  in  adults  and 
quite  frequently  in  young  people.  In  some  cases  it  is  a  neurosis. 
Nervous  excitement,  violent  emotions,  sorrow,  worry,  and  severe 
mental  labor  may  be  direct  causes. 

Neurasthenics  and  melancholies  often  suffer  from  it.  It  is  a 
frequent  concomitant  of  gastroptosis.  In  this  condition  the  hyper- 
chlorhydria is  not  the  result  of  the  nervous  condition  alone,  but  in 
part  due  to  the  ptosis,  with  resulting  circulatory  changes.  Its 
relief  by  Rose's  belt  is  the  proof,  as  reported  in  a  series  of  cases  at 
the  Manhattan  State  Hospital.^  It  occurs  with  mucous  colic,  in 
which  case  I  believe  gastroptosis  is  a  factor. 

Chlorosis  is  a  frequent  cause.  Irritation  of  the  mucous  membrane 
of  the  stomach  may  be  a  direct  factor,  as  from  bolting  the  food, 
large  quantities  of  cold  or  hot  drinks,  alcoholic  excess,  pickles,  rich 
condiments,  and  insufficient  mastication. 

^  Atonia  Gastrica,  Rose  and  Kemp. 


FUNCTIONAL    DISEASES    OF   THE    STOMACH  281 

Special  articles  of  food  or  drink  are  often  productive  of  it,  such 
as  very  strong  coffee.  Excessive  smoking  and  chewing  of  tobacco 
are  also  factors. 

Cholelithiasis  and  nephrolithiasis  are  said  to  be  causes. 

Hyperchlorhydria  is  the  most  frequent  accompaniment  of  gastric 
ulcer.  It  is  more  frequent  among  the  wealthy  class,  such  as  bankers, 
brokers,  and  professional  men,  though  it  occurs  among  the  poor. 
There  seems  to  be  no  special  predilection  for  either  sex. 

Symptoms. — They  rarely  appear  suddenly,  but  usually  develop 
gradually.  They  always  come  on  after  eating  and  never  on  an 
empty  stomach,  after  the  time  for  digestion  has  elapsed.  At  first 
the  patient  complains  of  a  disagreeable  sensation  or  an  uneasy 
feeling  about  one  to  three  hours  after  a  meal.  It  may  be  a  feeling 
of  pressure  or  fulness,  or  of  heat,  or  of  tingling.  This  increases  into 
a  feeling  of  distress  in  the  epigastric  region,  or  a  burning  sensation 
after  each  meal.     In  the  mild  cases  there  is  no  actual  pain. 

In  severe  cases  pain  may  be  marked,  with  acid  belching  and 
heart -burn,  and  the  patients  suffer  severely  and  in  some  cases  appear 
almost  in  a  state  of  collapse.  The  burning  may  be  felt  in  the  esopha- 
gus or  along  the  back  and  is  due  to  the  eructation  of  the  acid  contents. 
Violent  headache  often  accompanies  it.  Some  claim  they  can  feel 
spasmodic  movements  in  the  stomach.  This  is  due  to  contraction  of 
the  pylorus  and  an  increased  peristaltic  action  of  the  organ  endeavor- 
ing to  overcome  the  obstacle.  Mild  attacks  of  pain  last  for  a  brief 
period  of  time,  while  the  more  severe  attacks  persist  for  several  hours. 

Vomiting  occurs  occasionally  during  the  height  of  the  cardialgic 
attacks.  The  vomitus  is  very  acid  and  burning,  and  after  its  occur- 
rence relief,  as  a  rule,  results. 

In  some  cases  the  pain  appears  after  eating  certain  articles  of 
food,  and  patients  seem  to  have  idiosyncrasies,  such  as  to  coffee,  etc. 
The  attacks  are  not  always  directly  dependent  on  the  degree  of  the 
digestibility  of  the  food,  and  at  times  they  can  eat  indigestible 
material  without  discomfort;  whereas  at  other  times  digestible 
articles  of  diet  will  cause  pain.  Probably  the  nervous  element  plays 
a  part  in  these  cases,  causing  undue  irritation  of  the  nerves  of  secre- 
tion. 

Some  suffer  more  disturbance  after  a  small  meal,  while  after  a 
large  meal  they  have  no  distress.  This  is  readily  explained  by  the 
fact  that  the  larger  amount  of  food  combines  with  a  greater  portion 
of  the  free  HCl  secreted. 

Patients  when  the  symptoms  first  appear  can  ease  their  pain  by 
taking  nourishment,  especially  if  rich  in  albumin,  as  the  whites  of 
eggs  and  milk  or  meat.  It  also  disappears  after  the  administration 
of  an  alkali,  such  as  milk  of  magnesia  (Phillips),  Vichy,  or  soda 
bicarbonate.  Persons  living  chiefly  on  a  starch  diet  suffer  more 
intense  pain  than  those  who  live  largely  on  meat  and  eggs;  hence, 
the  character  of  the  food  has  frequently  a  relation  to  the  pain. 


282  DISEASES    OE   THE   STOMACH   AND   INTESTINES 

Appetite. — In  most  cases  the  appetite  is  very  good,  and  in  some 
is  greatly  increased.  Others  are  readily  satiated,  but  the  desire  for 
food  soon  comes  on  again. 

Thirst  is  at  times  increased  during  the  active  attack,  but  in 
many  cases  is  normal.  If  hyperchlorhydria  is  complicated  by 
dilatation  of  the  stomach,  thirst  is  present. 

Bowels. — Constipation  is,  as  a  rule,  present,  though  constipation 
and  diarrhea  may  alternate. 

Headache. — Severe  headache  often  occurs,  or  even  attacks  of 
dizziness,  generally  during  the  occurrence  of  gastric  pain. 

Nutrition. — These  patients  generally  do  not  lose  in  weight  nor 
present  the  aspect  of  being  very  sick.  They  are  rarely  particularly 
well  nourished  and  are  often  of  nervous  temperament  or  anemic. 
This  is  not  invariable,  as  one  has  at  times  to  treat  stout,  well- 
nourished  men,  high  livers,  and  inveterate  smokers  and  drinkers, 
who  suffer  from  this  complaint.  Rarely,  under  improper  diet  loss 
of  weight  may  occur. 

Nervous  Symptoms. — Some  patients  are  depressed,  nervous, 
suffer  from  insomnia,  and  are  neurasthenic.  Migraine  occurs  in 
others. 

Urine. — Acidity  of  the  urine  may  be  reduced  during  the  course 
of  digestion.     There  are  no  characteristic  features. 

Physical  Examination  of  the  Stomach. — During  intervals  between 
attacks  there  may  be  nothing  in  evidence. 

Percussion. — At  the  time  of  the  attack  the  stomach  may  be 
distended. 

Palpation. — The  greater  part  of  the  gastric  region  will  be  found 
to  be  tender  on  pressure  or  even  painful  in  some  cases.  The 
tenderness  covers  a  large  area,  generally  over  the  greater  part  of 
the  stomach,  often  in  the  region  of  the  pylorus  this  tenderness  is 
accentuated. 

Splashing  Sound. — This  can  be  produced  after  meals  or  after  the 
ingestion  of  water,  but  is  not  present  in  the  fasting  condition. 

Examination  of  the  Stomach  Contents. — This  is  the  decisive  test. 
If  the  stomach  is  aspirated  in  the  fasting  condition,  it  is  found  to 
be  empty,  or  only  a  few  cubic  centimeters  of  juice  can  be  secured. 

One  hour  after  Ewald's  test  breakfast  or  three  to  four  hours 
after  the  Leube-Riegel  test  dinner  the  stomach  contents  show  an 
extremely  acid  reaction,  often  two  to  three  times  higher  than  normal 
(from  IOO+  to  150  + ). 

It  is  not  sufficient  to  determine  the  total  acidity,  but  the  value 
of  the  free  hydrochloric  acid  is  the  important  feature.  Only  in 
hyperchlorhydria  is  it  increased,  and  in  this  condition  the  free  HCl 
causes  the  high  degree  of  acidity;  and  Topfer's  test  (dimeth}'l-amido- 
azobenzol)  shows  that  the  free  hydrochloric  acid  constitutes  the 
chief  content,  and  is  often  within  10+  to  15+  of  the  total  acidity. 
Mintz's  method  is  also  excellent. 


FUNCTIONAL    DISEASES   OF  THE   STOMACH  283 

The  digestive  power  is  very  good ;  a  small  disk  of  egg-albumen 
will  be  digested  in  a  short  time,  sometimes  within  one-half  to  one 
hour.  Three  to  four  hours  after  the  test  dinner  meat  will  be  found 
to  be  perfectly  digested,  while  starchy  substances  will  be  at  times 
unchanged  or  little  altered. 

Starch  or  erythrodextrin  will  be  found,  Lugol's  solution  giving 
a  blue  or  dark  red  reaction.  If,  however,  a  small  amount  of  starchy 
food  be  given  with  a  large  amount  of  albuminous  material,  while 
the  HCl  is  entering  into  combination  and  before  free  hydrochloric 
acid  appears,  the  normal  reduction  changes  in  the  starch  may  occur. 
With  large  quantities  of  amylaceous  material  the  brief  period  before 
the  appearance  of  hyperchlorhydria  will  not  allow  a  complete  con- 
version of  all  the  starch,  and  this  tends  to  remain  in  the  stomach  an 
abnormally  long  time  and  to  produce  fermentation. 

Absorption  from  the  stomach  is  not  disturbed;  potassium  iodid 
appears,  if  anything,  more  rapidly  in  the  saliva. 

Motor  Function. — This  is  not  impaired,  but  is  often  rather 
increased.  Two  hours  after  the  test  breakfast  or  six  to  seven  hours 
after  the  test  dinner  the  organ  is  found  to  be  empty  or  nearly  so. 
Salol  appears  as  salicyluric  acid  in  the  urine  an  hour  after  its  ingestion 
when  tested  for  with  ferric  chlorid  solution.  We  must  remember  that 
hyperchlorhydria  untreated,  with  fermentation  resulting  from 
improper  diet  (excessive  starch),  may  in  some  cases  produce  atony 
and  resulting  insufficiency.  Hypersecretion,  which  may  accompany 
hyperchlorhydria,  is  another  factor. 

Course. — It  may  be  rapid,  coming  on  suddenly  and  lasting  a 
short  time,  or  chronic  for  months  to  years.  It  often  varies  in  the 
early  stages  and  may  be  intermittent  in  its  character.  The  attack 
may  last  for  days,  weeks,  or  even  months,  and  then  there  be  a  free 
interval  for  a  considerable  period  of  time.  It  can  recur  without  any 
apparent  cause,  or  result  from  some  mental  shock  or  worry,  or  from 
some  dietary  indiscretion.  Gradually  the  hyperchlorhydria  becomes 
more  frequent  and  at  last  the  condition  becomes  permanent. 

In  rare  cases  the  attacks  appear  to  come  on  later  than  usual  and 
vorhiting  of  an  acid  mass  of  undigested  food  may  occur,  showing 
the  contents  were  retained  an  abnormally  long  time.  This  is  undoubt- 
edly due  to  spasmodic  closure  of  the  pylorus  from  irritation  by  the 
acid  contents. 

Atony  and  even  atonic  dilatation  may  develop  from  this  type, 
and  hypersecretion  (gastrosuccorrhea)  may  result  in  some  cases. 

Prognosis. — The  prognosis  is,  as  a  rule,  good.  Many  patients 
can  be  completely  cured.  In  some  very  old  or  severe  cases  there 
is  a  tendency  to  relapses.     The  disease  is  not  dangerous  to  life. 

Those  in  whom  the  nerv^ous  element  plavs  a  part  often  do  not 
readily  respond  to  treatment  and  are  a  source  of  discouragement  to 
the  physician.  Relapses,  in  spite  of  the  greatest  care  and  for  no 
apparent  reason,  are  not  infrequent. 


284  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

If  atony  or  dilatation  of  the  stomach  complicate  the  hyperchlor- 
hydria,  the  prognosis  as  to  cure  is  not  as  favorable. 

Pathology. — As  the  cases  are  not  fatal,  it  is  hence  unknown. 
In  one  case,  dying  of  intercurrent  disease,  a  few  erosions  were  found. 
It  is  evidently  a  disorder  of  the  secretory  function. 

Diagnosis. — The  diagnosis  of  hyperchlorhydria  can  be  made 
from  the  examination  of  the  gastric  contents: 

1.  An  hour  after  Ewald's  test  breakfast  the  acidity  is  found 
increased,  due  to  the  increased  quantity  of  free  hydrochloric  acid. 

2.  In  the  fasting  condition  the  stomach  is  found  empty  or  nearly 
so.     (This  excludes  gastrosuccorrhea.) 

Furthermore,  the  patient  suffers  from  certain  subjective  symp- 
toms: 

1.  Discomfort  or,  more  generally,  a  pain  which  comes  on  from 
one  to  three  hours  after  a  meal.  This  is  directly  dependent  upon 
the  ingestion  of  food.  It  is  not  a  continuous  pain  and  there  are 
intervals  of  relief.  The  character  of  the  food  and  the  quantity  have 
a  bearing.  Starchy  food  readily  produces  it  and  a  light  meal  more 
than  a  full  meal.  The  latter,  when  rich  in  albumin,  often  causes 
no  disturbance.  The  pain  may  be  "a  dead,  dull  pain,  with  a  gnawing 
sensation, "  or  may  be  of  a  burning  character.  The  administration 
of  an  alkali,  such  as  Vich}^  or  sodium  bicarbonate,  relieves  the  pain 
by  neutralizing  the  acid;  or  milk,  raw  eggs,  or  a  meat  sandwich,  by 
binding  the  free  acid,  produces  the  same  result. 

2.  In  others  there  is  more  the  feeling  of  a  heat  or  burning  in  the 
stomach  or  the  feeling  of  a  sour  stomach. 

3.  Appetite  and  thirst  are  generally  normal. 

4.  No  cachexia. 

5.  Marked  constipation  is  the  rule. 

6.  Some  cases  are  quite  nervous  or  even  neurasthenic. 
Complications. — It   is   often   necessary   to   determine   whether 

atonv,  dilatation  of  the  stomach,  or  gastroptosis  are  associated  with 
the  hyperchlorhydria. 

Simple  Atony. — Presence  of  the  splashing  sound  and  100  cc.  or 
more  of  gastric  contents  aspirated  one  hour  or  more  after  Ewald's 
test  breakfast ;  or  the  splash  with  the  presence  of  food  in  the  stomach 
six  or  seven  hours  after  the  test  meal;  the  lower  border  is  in  normal 
position  as  determined  by  the  splash  and  by  percussion. 

Dilatation. — Splash  at  the  umbilicus  or  below  shows  descent  of 
lower  border.  Percussion  alone  or  with  inflation,  or  gastrodiaphany 
substantiate  this  finding;  there  is  no  descent  of  the  upper  border. 
Kidneys  are  normal  in  position. 

Gastroptosis. — Splash  at  the  umbilicus  and  below  shows  descent 
of  lower  border. 

Movable  kidney  is  diagnostic  if  found  in  addition.  There  is 
diastasis  of  the  recti  muscles;  inflation  or  gastrodiaphany  shows 
descent  of  the  upper  border  of  the  stomach. 


FUNCTIONAI.    DISEASES    OF   THE    STOMACH  285 

Differential  Diagnosis.— Acid  Gastritis. — Hyperacidity  is  pres- 
ent plus  abundant  stomach  mucus. 

Hypersecretion  (Gastrosuccorrhea) . — The  stomach  in  the  fasting 
condition  contains  75  to  100  cc.  or  more  of  very  acid  gastric  juice. 
The  persistent  appearance  of  20  cc.  of  gastric  juice  in  the  fasting 
stomach  is  considered  pathognomonic  by  many.  Severe  attacks 
of  pain  and  vomiting  generally  occur  during  the  night  or  early 
morning. 

Biliary  Colic. — Pains  are  later  (four  to  five  hours  after  meals)  or 
independent  of  meals.  The  pains  of  hyperchlorhydria  are  dependent 
on  the  meals.  Pains  of  biliary  colic  are  not  relieved  by  alkalis  and 
they  extend  over  the  right  epigastrium  and  hypochondrium,  and 
frequently  to  the  right  shoulder  or  right  axillary  region.  A  patient 
with  biliary  coUc  or  even  after  the  attack  has  no  appetite  and  cannot 
eat. 

The  appetite  is  good  in  hyperchlorhydria. 

The  gall-bladder  is  painful  on  pressure  and  at  times  swollen. 
Icterus  may  be  present.  Gall-stones  at  times  are  found  in  the  stool. 
Leukocytosis  is  present  in  biliary  colic  if  inflammation  is  associated. 
Sometimes  the  differential  diagnosis  is  difficult.  Gastric  analysis  may 
be  necessary  to  determine  it,^  though  occasionally  both  conditions 
occur  together. 

Ulcer  of  the  Stomach. — Epigastric  pain  is  intense,  appears  shortly 
after  the  ingestion  of  food;  local  tenderness  on  pressure  and  pain 
increased  thereby.  Pain  disappears  at  the  end  of  digestion.  There 
are  the  dorsal  pain  and  vomiting  in  many  cases  soon  after  meals. 

Hematemesis  occurs  or  occult  blood-  is  found  in  the  gastric  con- 
tents or  stool.     Ulcer  is  more  frequent  in  women. 

Nervous  Gastralgia. — More  frequent  in  women  from  eighteen  to 
thirty  years.  Pain  appears  without  regularity,  and  is  in  no  way 
dependent  upon  the  meals  or  character  of  food.  Is  relieved  by 
pressure.  Intervals  of  perfect  health ;  nervous  temperament  always 
present.     Gastric  analyses  often  varies  in  the  same  case. 

Treatment. — The  treatment  comprises,  first,  the  removal  of  the 
causes  of  hyperchlorhydria;  and  second,  the  cure  of  the  condition 
itself. 

Removal  of  the  Causes. — Interdict  tobacco  smoking  and  chewing. 
If  a  cigar  or  cigarette  holder  is  employed,  smoking  once  or  twice  a 
day  I  believe  may  be  harmless,  as  it  prevents  swallowing  saliva 
impregnated  with  tobacco  juice,  the  chief  source  of  irritation  in  my 
opinion.  Alcohol  in  every  form,  including  wines  and  beers,  should 
be  prohibited.  All  kinds  of  acids,  such  as  acetic,  tartaric,  or  citric, 
should  be  forbidden;  and  all  foods  prepared  with  them,  such  as  with 
vinegar  or  lemon  juice;  and  all  acid  or  acidulated  drinks. 

Condiments,  such  as  pepper,   ginger,  horseradish,  etc.,   pickles, 

1  The  presence  of  Head's  gall-bladder  zone  may  aid  diagnosis. 

2  The  discovery  of  occult  blood  is  often  the  determining  factor  in  our  diagnosis. 


286  DISBASES   OF   THE    STOMACH   AND   INTESTINES 

mustard,  paprika,  nuts,  acid  fruits,  grapefruit,  and  radishes,  should 
be  prohibited. 

Avoid  all  extremes  of  heat  and  cold  in  food  and  drink. 

Thorough  mastication  of  the  food  should  be  enjoined. 

Nervous  conditions,  when  present,  should  be  treated. 

Hygienic  regulations  are  important. 

Overwork  and  mental  anxiety  are  factors  in  the  production  of 
hyperchlorhydria.  Brokers,  professional,  and  business  men  must  be 
relieved  temporarily  from  overwork  and  worry  by  being  sent  into  the 
country,  where  various  open-air  amusements,  such  as  golf,  horseback 
riding,  driving,  walking,  etc.,  can  be  indulged  in.  If  the  patient 
have  a  taste  for  fishing  or  shooting,  such  diversions  are  excellent. 
I  have  seen  a  few  weeks  in  camp  work  wonders. 

Those  indulging  in  a  continuous  round  of  social  festivities  should 
be  compelled  to  lead  a  quiet  life. 

On  the  other  hand,  there  are  many  people  of  wealth  with  no 
occupation  whatever  who  become  entirely  self-centered  and  nervous 
therefrom,  and  for  such  a  class  of  persons  occupation  is  of  great  value. 

Hydrotherapy,  such  as  sponge-baths,  douches,  etc.,  are  of  service; 
also  a  moderate  indulgence  in  calisthenics  (ten  minutes  morning  and 
night). 

For  the  cure  of  the  hyperchlorhydria  there  are  practically  two 
methods  used,  alone  or  in  combination: 

We  may  bind  the  excess  of  free  hydrochloric  acid  by  the  adminis- 
tration of  large  quantities  of  proteids  or  we  may  neutralize  the 
excessive  acid  by  the  administration  of  an  alkali.  Clinical  observa- 
tion has  demonstrated  that  those  articles  of  food  which  are  capable 
of  binding  large  quantities  of  HCl  are  borne  the  best.  The  burning 
feeling  of  distress  or  pain  is  relieved  by  the  administration  of  albuminous 
food.  Carbohydrates,  if  given  in  any  quantity,  cause  distress.  The 
diet  is,  therefore,  of  greatest  importance. 

Diet  in  Hyperchlorhydria. — As  noted  under  prophylaxis,  all 
articles  which  are  liable  to  overstimulate  the  secretory  glands  of  the 
stomach  should  be  forbidden.  Among  such  are  acids,  all  spices, 
as  pepper  and  mustard,  pickles,  horseradish,  olives,  acid  fruits,  beers, 
and  wines. 

The  food  should  be  rich  in  albumin,  such  as  chops,  steak,  roast 
beef,  mutton,  game,  eggs,  milk,  oysters,  and  fish.  Bread  and  butter 
can  be  taken,  the  former  in  moderation.  Green  vegetables,  such  as 
spinach,  asparagus,  lettuce,  peas  and  string  beans,  potatoes,  rice, 
and  other  cereals  should  be  given  in  small  quantity.  They  should 
be  taken  in  combination  with  large  amounts  of  albuminous  food. 

Alcohol  in  all  forms,  including  beers  and  wines,  I  believe  should 
be  avoided,  also  coffee;  though  some  allow  a  small  amount  of  beer 
and  very  weak  coffee.  Fleiner  has  demonstrated  that  egg-albumen 
binds  more  free  hydrochloric  acid  than  any  other  food.  Among 
other  articles  especially  suitable  for  this  purpose  he  recommends 


FUNCTIONAL    DISEASES    OP   THE    STOMACH  287 

boiled  veal,  beef,  mutton,  raw  ham,  Leube-Rosenthal's  beef  solution, 
boiled  ham,  boiled  pork,  Swiss  cheese,  Roquefort,  pumpernickel, 
milk,  and  cocoa. 

In  my  own  experience  I  have  found  gelatin^  an  excellent  remedy, 
employing  i  or  2,  or  even  3  ounces  of  a  5  to  10  per  cent,  gelatin 
solution  flavored  with  a  pinch  of  sugar  or  a  little  vanilla,  and  given 
midway  between  meals.  The  value  of  egg-albumen  and  cocoa  is 
marked.  Starchy  foods  that  have  been  well  dextrinized,  such  as 
Zwieback  and  toast,  are  more  readily  digested. 

Strauss  has  shown  that  if  carbohydrates  are  introduced  in  the 
form  of  sugars  in  solution  they  do  not  markedly  increase  HCl  secre- 
tion. He  gives  200  to  300  cc.  of  a  20  per  cent,  dextrose  solution 
during  the  day. 

Considerable  water  should  be  taken  during  meals,  or  Apollinaris 
and  seltzer,  if  no  atony  is  present. 

Fats,  such  as  butter  and  cream,  are  of  value.  Since  the  carbo- 
hydrates are  restricted  and  additional  calories  must  be  secured, 
Strauss,  Bwald,  and  others  advise  their  use.  Furthermore,  fats 
seem  to  lessen  the  acidity  or  possibly  the  irritable  tendency  of  the 
mucous  membrane.     Cream  has  been  thus  recommended. 

For  some  years  I  have  been  accustomed  to  administer  olive  oil 
once  or  even  three  times  daily  before  meals  in  obstinate  cases  of 
hyperchlorhydria,  using  from  oss  to  j  (16.0-32.0),  suspended  in 
water.  This  has  lessened  the  hyperacidity.  In  the  same  way, 
glycerin,  oss  to  ij  (2.0-8.0),  mixed  in  water,  may  be  used.  Illo- 
way-  employed  it  in  one  case. 

If  we  attempt  to  treat  hyperchlorhydria  by  diet  alone,  we  should 
give  three  additional  feedings  at  a  time  after  the  regular  three  meals, 
such  as  would  bind  the  excessive  hydrochloric  acid  and  prevent  the 
symptoms.  The  extra  feedings  may  consist  of  kumyss,  matzoon 
and  Vichy,  bacillac,  bouillon,  a  sandwich,  milk,  raw  egg  (especially  the 
whites)  and  milk,  with  crackers  or  bread  and  butter.  One  can  select 
a  diet  from  the  tables  with  a  sufficient  number  of  calories. 

For  practical  purposes  an  improvement  in  nutrition,  i.  e.,  some 
increase  in  weight,  should  be  secured,  even  though  slight,  in  addition 
to  the  amelioration  of  symptoms.  This  refers  only  to  those  of  thin 
habit,  not  to  the  well  nourished.  The  use  of  the  scales,  weighing  at 
stated  intervals,  is  of  radical  importance.  Assimilation  differs  in 
individual  cases,  and  though  on  paper  the  calories  may  be  correct, 
a  loss  of  weight  shows  a  radical  error  in  the  treatment.  The  follow- 
ing is  a  sample  dietary,  such  as  is  usually  recommended  for  a 
patient  of  good  physique  and  quite  active.  The  content  of  pro- 
teid  is  very  high  as  compared  with  Chittenden's  scale,  which  I 
advocate  in  health.  It  is  frequently  advisable  to  diminish  the 
quantity    of    meat    and    substitute    milk,    matzoon,     kumyss,     or 

^  Calves'  foot  or  chicken  jelly  are  excellent. 

2  New  York  Med.  Jour.,  May  25,  June  i,  15,  and  29,  1901. 


288  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

bacillac.  Ivactone-buttermilk  is  also  excellent.  Gelatin  solutions 
bind  the  free  hydrochloric  acid  in  a  satisfactory  manner.  Depend- 
ing on  the  normal  weight,  height,  and  occupation,  the  diet  must  be 
formulated  in  every  case: 

Calories. 
7.30  A.  M. — 250  cc.  milk,  cocoa,  2  eggs,  3  zwieback,  and  butter 

(gm.  20) 690 

10.30  A.  M. — 200  cc.  milk,  with   i  raw  egg,  or  matzoon  and 
Vichy  125  cc,  or  kumyss  250  cc,  or  milk  250 

cc,  or  bouillon  with  i  raw  egg  (approximately) .  240 

Bread  2  slices,  or  crackers  2  oz.  (gm.  60) 160 

Butter  gm.   20,  water,  or  ApoUinaris,  or  Vichy 

250  cc,  occasionally  weak  tea 163 

1.30  p.  M. — Chops,  steak,  beef,  or  mutton,  100  gm.  (about).  .  200 

Mashed  potatoes,  30  gm 37 

Spinach,  30  gm 12 

Bread  (i  slice),  30  gm 81 

Butter,  10  gm 80 

4.30  p.  M. — Same  as  at  10.30  a.  m 563 

7.00  p.  M. — Soup  (barley),  200  cc 100 

Meat,  broiled,  100  gm 200 

Spinach  or  peas,  50  gm 30 

Potatoes  mashed  with  milk,  50  gm 80 

Weak  tea,  100  cc.  (three-fourths  mUk) 64 

Toast  ( I  slice) 75 

Butter,  10  gm 81 

10.00  p.  M. — Milk  and  Vichy,  aa  100  cc 64 

Total  calories 2920 

Various  modifications  may  be  made. 

Coffee  I  interdict.  All  fried  food  should  be  forbidden,  as  should 
hot  breads,  hot  biscuits,  and  rich  desserts.  The  food  should  not  be 
excessively  hot  or  cold.  The  patient  should  eat  slowly,  masticate 
thoroughly,  and  rest  after  eating  for  at  least  twenty  minutes  to 
one-half  hour. 

Illoway  and  Bouveret  advocate  only  three  meals  a  day,  with  a 
sandwich  at  bedtime  in  some  cases.  They  believe  the  stomach 
should  have  an  interval  of  rest  so  as  to  become  perfectly  emptied. 
Practically,  Illoway's  only  medication  is  one-half  glass  of  French 
Vichy,  given  at  10  to  11  a.  m.,  at  4  to  5  p.  m.,  and  at  night,  if  the  sand- 
wich is  omitted. 

They  beheve  that  unless  the  stomach  have  some  rest,  atony  or 
atonic  dilatation  may  result. 

On  the  other  hand,  some  patients  can  only  eat  a  small  amount 
of  food  at  a  time,  have  the  desire  to  eat  at  frequent  intervals,  and 
feel  better  if  they  do  so.  Repeated  feedings  are  difficult  to  follow 
out  in  some  cases,  so  conditions  vary. 

My  method  is  to  give  the  three  regular  meals  a  day  with  diminished 
carbohydrates,  with  the  alkaHs  an  hour  to  an  hour  and  a  half  or 
even  two  hours  later.  If  it  is  necessary  to  improve  nutrition,  addi- 
tional feedings  are  given,  a  glass  of  kumyss,  or  milk  and  raw  egg, 
or  matzoon  and  Vichy  or  i  to  2  ounces  of  10  per  cent,  gelatin 
solution  (sweetened)  between  meals  or  if  pain  comes  on  after  the 
administration  of  the  alkaH.     These  foods  can  be  alternated. 


FUNCTIONAL   DISEASES    OF    THE)    STOMACH  289 

Medication. — Among  the  alkalis  that  are  of  value  are  Vichy, 
imported  or  siphon,  bicarbonate  of  soda,  milk  of  magnesia  (Phil- 
lips), magnesia  usta,  magnesia  ammoniophosphorica,  and  biborate 
of  soda  (Jaworski). 

A  little  sugar  of  milk  can  be  added  to  the  soda  or  magnesia 
preparations  to  make  them  more  agreeable.  If  the  hyperchlorhydria 
is  complicated  by  atony,  then  bicarbonate  of  soda  (which  generates 
considerable  carbonic  acid  gas)  would  be  objectionable. 

The  following  rule  should  be  carried  out  as  regards  the  adminis- 
tration of  the  alkalis:  "Give  them  in  ample  time  to  anticipate  the 
appearance  of  symptoms  by  a  considerable  margin."  They  should 
be  administered  t.  i.  d.  after  meals,  depending  upon  the  time  of 
appearance  of  symptoms.  Repeat  the  dose  if  the  symptoms  begin 
later,  unless  albuminous  food  is  given  as  a  substitute. 

The  magnesia  preparations  have  the  tendency  to  move  the 
bowels  and  hence  are  of  special  value.  If  the  result  is  too  active, 
combine  the  magnesia  with  varying  proportions  of  soda  bicarbonate 
or  give  the  latter  alone,  or  give  bismuth  subnitrate  with  the  magnesia. 
Magnesia  usta  will  neutralize  about  four  times  more  acid  than  soda 
bicarbonate. 

The  dosages  are  as  follows,  given  from  one  to  two  hours  after 
meals  t.  i.  d. : 

Vichy 175  to  250  cc.  (^i  glassful). 

Vichy ^  to  I  glassful  plus  sod.  bicarb.  J  to  1  tea- 
spoonful  (2.0-4.0).  Allow  this  to  become 
fiat  (effervescence  to  disappear). 

Sod.  bicarb ^  to  i  (2.0-4.0)  teaspoonful  in  one-third  glass- 
ful of  water. 

I^.     Magnesia  usta, 

Sod.  bicarb aa 

Dose,  i  to  1  teaspoonful  (2.0-4.0)  in  water  t.  i.  d. 

A  little  sugar  of  milk  or  rr^j  oU  of  peppermint  may  be  added  to  flavor. 

If  the  bowels  move  too  freely,  diminish  magnesia,  then  give: 

I^.     Magnesia  usta oSS  (16. o") 

Sod.  bicarb q.  s.  oij  (64.0). — M. 

Dose,  i  to  I  teaspoonful  (2.0-4.0)  in  water. 

If  necessary,  bismuth  subnitrate,  oij  to  Sss  (8.0-16.0),  may  be  added. 

I^.     Sod.  bicarb oj  (320) 

Magnesia  usta oss  (16.0) 

Magnesia  ammon.  phos oss  (16.0). — M. 

Dose,  2  to  1  (2.0-4.0)  teaspoonful  in  water. 

I^.     Magnesia  usta 5ss  (16.0) 

Pulv.  rhu gm.  15  (i.o). 

Soda  bicarb oss  (16.0) 

Sugar  of  milk oss  (16.0). — M. 

Dose,  ^  teaspoonful  (2.0)  in  water  if  costive  or, 

Milk  of  magnesia  (Phillips) 5  j  to  iv  (4.0-16.0),  in 

water  t.  i.  d. 
19 


290  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

This  I  have  found  to  be  an  excellent  preparation,  especially  where 
constipation  is  marked.  It  is  one  of  the  most  serviceable  remedies 
for  hyperchlorhydria. 

Sod.   biborate gr.  x  to  xv  (0.6-1.0), 

in  water  (Jaworski). 

has  been  recommended. 

The  use  of  Carlsbad  water  or  a  glass  of  the  imported  Carlsbad 
salts,  5j  to  ij  (4.0-8.0),  in  warm  water  on  rising,  lessens  acidity  and 
helps  the  bowels. 

Wolff's  artificial  Carlsbad  mixture  consists  of: 

I^.     Sod.  sulph 30.0 

Sulph.  potass 5.0 

Sod.  chlorid 30.0 

Sod.  carb 750 

Sod.  biborate lo.o. — M. 

He  adds  sod.  biborate  on  account  of  Jaworski' s  recommendation. 
Dose,  5ss  (,2.0)  in  one-half  glassful  of  warm  water  two  hours  before  meals. 

In  some  cases  I  give  olive  oil,  oss  to  j  (16.0-30.0)  or  more,  or 
glycerin,  3ss  to  ij  (2.0-8.0),  in  a  little  water  before  meals,  to  lessen 
gastric  irritability;  bismuth  subnitrate,  gr.  15  (i.o),  given  with  the 
olive  oil  is  often  useful. 

If  the  pain  is  severe  the  administration  of  belladonna  before 
secretion  commences,  in  order  to  lessen  the  gastric  juice,  is  of  value. 
At  the  time  of  pain  it  is  too  late.  It  is  serviceable  also  in  obstinate 
cases,  thus  before  meals : 

I^.     Tinct.  belladonna oiss  (6.0) 

Aq.  destil q.  s.  oij  (60.0). — M. 

Dose,  J  to  I  teaspoonful  (2.0-4.0),  or  larger  dose  of  tinct.  belladonna,  up  to 
10  drops,  may  be  given. 

or 

Ext.  belladonna gr.  ^  to  J  (.01-.02). 

or 

Atropin gr.  j^q  (0.0006). 

Illoway  suggests: 

I^.     Tinct.  aconite  root 6  drops 

Tinct.  belladonna 25  drops 

Aq.  destil q.  s.  5 j  (30.0). — M. 

Dose,  I  teaspoonful  (4.0)  on  rising  and  a  second  dose  in  half  an  hour.  No 
-Tiore. 

If  the  pain  is  extremely  severe  and  not  relieved  by  an  alkali, 
a  small  dose  of  codein,  gr.  |-  to  I  (0.008-0.016),  may  be  required. 
This  may  even  be  given  by  hypodermic  with  excellent  results.  Mor- 
phin  in  same  dosage  is  rarely  necessary  and  should  only  be  given  by 
the  physician. 

The  application  of  heat  to  the  epigastrium  by  moist  compresses, 
hot-water  bag,  or  poultice  is  of  service. 

If  the  patient  is  very  restless  and  disturbed   one  of  the  bromids. 


FUNCTIONAL    DISEASES    OF   THE    STOMACH  29I 

strontium  bromid,  sodium  bromid,  or  ammonium  bromid,  may  be 
given  in  gr.  x  to  xv  (.06-1.0)  doses  for  a  brief  period. 

In  obstinate  cases,  silver  nitrate,  gr.  i  to  ^  (0.008-0.016)  t.  i.  d. 
or  in  solution,  has  been  recommended  to  relieve  gastric  secretion,  or 
occasionally  a  douche  or  spray  with  silver  nitrate  (i :  2000),  followed 
by  lavage  with  water.  If  the  douche  is  used,  lavage  is  unnecessary 
unless  there  is  a  complicating  atonic  dilatation.  If  one  sees  the 
patient  during  a  severe  attack  of  pain,  aromatic  spirits  of  ammonia, 
5ss  to  j  (2.0-4.0),  diluted  well  with  water;  lime-water,  oj  to  ij  (30.0- 
60.0),  mist,  cretae,  oss  to  j  (16.0-30.0),  or  bicarbonate  of  soda  or  the 
magnesia  preparations  can  be  given  at  once. 

Sometimes  sodium  bicarbonate  distends  the  stomach  and  causes 
more  pain.  Emesis  is  often  a  relief,  and  at  times,  when  other  treat- 
ment fails,  lavage  may  be  used  as  a  temporary  method. 

Electricity  has  been  recommended,  especially  by  Einhorn,  for 
the  treatment  of  hyperacidity. 

Internal  galvanization  has  been  suggested  for  the  relief  of  pain. 
It  seems  to  be  impractical. 

In  cases  when  constipation  is  obstinate  or  when  atony  is  present 
it  might  be  of  service,  either  the  intragastric  or,  preferably,  the 
percutaneous  method  of  faradization. 

Bowels. — ]\Iassage,  vibratory  massage,  and  rectal  injections  of 
olive  oil  are  of  service,  as  well  as  out-of-door  exercise,  horseback 
riding,  etc.  Remedies  such  as  cascara,  aloes,  phenolax,  etc.,  may  be 
at  times  temporarily  necessary. 

If  there  is  atony,  dilatation,  or  ulcer,  these  conditions  must  be 
treated.     Rose's  belt  is  indicated  for  atony  or  atonic  ectasia. 

To  briefly  recapitulate.     I  have  found  the  following  of  value: 

Carlsbad  salts  on  rising. 

Milk  of  magnesia  (Phillips)  or  magnesia  usta,  alone  or  with  soda 
bicarb.,  or  Vichy  and  soda  bicarb.,  one  to  two  hours  after  meals; 
midway  between  the  chief  meals  a  little  milk  and  raw  eggs,  kumyss, 
matzoon  and  Vich}^,  or  i  to  2  ounces  (30.0-60.0)  of  gelatin  solution 
(5  to  10  per  cent.). 

In  some  cases  olive  oil  before  luncheon  and  dinner,  and  belladonna 
extract  or  tincture  when  required. 

The  proper  diet  must  be  followed. 

GASTROSUCCORRHEA  (CONTINUOUS  SECRETION  OF  GASTRIC 

JUICE) 

{Synonyms. — Hypersecretion;  Parasecretion;  Excessive  Flow  of  Gastric  Juice; 
Reichmann's  Disease;  Gastroxynsis — Rossbach.) 

Gastrosuccorrhea  is  a  perversion  of  function  in  which  the  glands 
of  the  stomach  secrete  large  quantities  of  gastric  juice  even  when  the 
stomach  is  empty,  and  hence  when  there  is  no  irritation  from  ingested 
food.  The  diagnosis  rests  on  the  removal  from  the  stomach  in  the 
fasting  condition  of  a  considerable  quantity  of  gastric  juice,  with 


292  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

the  addition  of  symptoms  which  present  a  characteristic  picture. 
To  Reichmann  the  credit  is  due  of  having  first  called  attention  to 
this  perversion  of  function. 

Gastrosuccorrhea  may  be  classified  in  two  types: 

1.  Gastrosuccorrhea  continua  periodica  or  the  intermittent  form 
of  hypersecretion;  the  attacks  occur  at  irregular  intervals. 

2.  Gastrosuccorrhea  continua  chronica  or  chronic  hypersecretion. 
Though  some  believe  that  hypersecretion  is  a  purely  secretory 

neurosis,  other  factors  can  also  produce  it.  Unquestionably,  nervous 
conditions,  such  as  mental  excitement  or  mental  overexertion,  may 
be  the  direct  cause  in  some  cases;  hence,  gastrosuccorrhea  may  be 
a  pure  neurosis. 

On  the  other  hand,  direct  irritation  of  the  mucous  membrane 
can  be  the  cause;  in  fact,  the  same  factors  that  produce  hyperchlor- 
hydria,  such  as  rapid  eating,  indigestible  food,  spices  and  condiments, 
abuse  of  alcohol,  bolting  the  food,  excessively  hot  or  cold  food  or 
drink,  etc. 

Hyperchlorhydria  of  long  standing,  especially  if  neglected,  may 
be  a  factor  in  the  ultimate  production  of  continuous  secretion.  In 
some  of  the  gastric  crises  of  locomotor  ataxia  gastrosuccorrhea  is 
at  times  observed. 

Hypersecretion  is  also  at  times  an  accompaniment  of  dilatation 
of  the  stomach,  either  of  the  atonic  type  or,  more  frequently,  in  the 
form  due  to  stenosis  of  the  pylorus.  It  also  may  occur  with  ulcer  of 
the  stomach.  It  can  even  accompany  acute  dilatation  of  the  stomach, 
especially  in  that  form  engrafted  on  a  chronic  stenotic  dilatation,  to 
which  I  refer  under  Acute  Ectasy.     Tetany  may  be  rarely  associated. 

In  many  cases  of  hypersecretion  disturbances  of  the  motor 
functions  of  the  stomach  are  present  in  addition. 

GASTROSUCCORRHEA  (CONTINUA  PERIODICA) 

{Synonyms. — Intermittent  Secretion  of  Gastric  Juice;  Intermittent  Hypersecre- 
tion;  Gastroxynsis;  Periodic  Continuous  Flow  of  Gastric  Juice.) 

This  type  of  hypersecretion  is  characterized  by  an  acute  attack 
of  continuous  secretion  of  gastric  juice  associated  with  severe  pains 
in  the  stomach,  usually  spasmodic  in  character,  and  by  vomiting  of 
acid  fluid,  the  attacks  usually  occurring  in  the  night  or  early  morning 
and  at  irregular  intervals;  hence  it  is  known  as  intermittent  or 
periodic.  Probably  this  condition  is  more  frequent  among  nervous 
cases  than  we  generally  suppose.  I  have  been  able  to  absolutely 
determine  in  several  cases  of  supposed  intermittent  attacks  of  acute 
gastritis,  or  so-called  acute  bilious  attacks,  that  this  condition  of 
intermittent  hypersecretion  was  present. 

History. — Reichmann^  was  the  first  to  describe  this  perversion 
of  function,  and  Rossbach,^  under  the  nomenclature  gastroxynsis, 

^  Berl.  klin.  Wochenschr.,  1882,  No.  40. 
ZDeutsch.  Arch.  f.  klin.  Med.,  1883,  Bd.  35. 


FUNCTIONAL    DISEASES    OF   THE    STOMACH  293 

described  what  is  generally  considered  the  same  disease.  Sahli, 
Riegel,  and  many  others  have  written  on  it. 

Etiology. — In  some  cases  it  is  a  neurosis,  or  the  result  of  mental 
overexcitement  or  of  overexertion;  irritation  of  the  gastric  mucous 
membrane,  as  from  cold  water,  or  smoking,  spices,  etc.,  may  pre- 
cipitate an  attack. 

It  is  associated  with  the  gastric  crises  of  locomotor  ataxia  in 
some  patients,  or  with  organic  affections  of  the  peripheral  or  central 
nervous  system,  with  gastric  ulcer,  or  with  the  stenotic  form  of  ectasia 
or  with  acute  dilatation  of  the  stomach.  These  are  not  pure  cases, 
but  have  the  additional  symptoms  incident  to  the  disease. 

Symptoms. — These  usually  begin  during  the  night.  The  patient, 
who  is  generally  apparently  perfectly  well,  suddenly  begins  to  feel 
discomfort  in  the  gastric  region,  w^hich  is  rapidly  followed  by  pain 
of  severe  type  and  generally  spasmodic  in  character.  There  is  nausea, 
a  feeling  of  faintness,  and  the  patient  is  obliged  to  assume  the  recum- 
bent position.  He  grows  pale,  the  extremities  become  cold,  and  the 
abdomen  at  times  is  sunken  and  the  pulse  rapid  and  feeble.  The 
nausea  becomes  worse  and  worse  and  soon  a  violent  attack  of  vom- 
iting of  a  large  amount  of  acid  fluid  takes  place. 

There  is  temporary  relief,  but  the  symptoms  begin  again,  and 
after  a  short  period  the  patient  again  vomits  up  a  large  quantity  of 
fluid,  far  out  of  proportion  to  the  amount  previously  ingested. 

During  the  attack  the  appetite  is  lost  and  there  is  extreme  thirst. 
Severe  headache  and  constipation  generally  accompany  these 
attacks. 

These  attacks  generally  occur  in  the  middle  of  the  night  or 
early  in  the  morning,  and  awaken  the  patient  by  the  pain,  if  he  be 
sleeping. 

During  the  attack  the  stomach  is  tender  on  pressure  and  there 
is  a  good  deal  of  heart -burn  and  acid  belching,  the  urine  is  scanty, 
alkaline,  and  of  high  specific  gravity. 

Character  of  the  Vomitus. — The  fluid  is  watery  and  ver}^  acid.  It 
may  be  clear  or  somew^hat  tinged  with  bile  (yellowish  green). 

There  may  be  particles  of  food  in  the  first  vomit  if  motor  insuf- 
ficiency is  associated  with  the  condition,  but  in  many  cases  there  is 
simply  the  clear  gastric  juice  alone  or  mixed  with  bile.  If  this  fluid 
be  examined  it  will  be  found  to  contain  free  hydrochloric  acid  in 
considerable  quantity,  rennet,  and  pepsin.  The  desire  to  vomit 
frequently  persists  and  generally  several  attacks  of  vomiting  succeed 
each  other.  Even  though  the  patient  abstain  from  all  fluid ,  in  a  few 
hours  or  less  he  will  again  vomit  a  large  quantity  of  gastric  juice. 
Rarely  the  vomitus  may  contain  traces  of  blood,  which  does  not 
necessarily  mean  an  ulcer.  This  condition  may  last  for  several 
hours  or  for  several  days,  when  gradually  the  vomiting  stops,  the 
nausea  and  pain  subside,  and  the  patient  begins  to  desire  food. 
Gradually  the  appetite  returns,  the  food  is  retained,  in  a  few  days 


294  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

"he  begins  to  feel  nearly  well,  and  in  a  brief  time  is  apparently  in 
perfect  health. 

The  patient  may  continue  in  good  health  for  weeks,  months,  or 
a  year,  and  then  have  a  recurrence.  The  intermissions  of  good 
health,  on  the  other  hand,  may  become  shorter  until,  finally,  the 
intermittent    gastrosuccorrhea    becomes    chronic. 

In  many  cases  during  the  intermissions,  if  the  gastric  contents 
are  analyzed,  they  will  be  found  to  be  perfectly  normal.  On  the 
other  hand,  some  cases  may  suffer  from  mild  symptoms  of  hyper- 
chlorhydria,  and  such  a  condition  will  be  found  to  exist  on  examina- 
tion. 

Diagnosis. — This  can  be  made  by  the  characteristic  symptoms 
beginning  during  the  night,  the  vomiting  of  pure  gastric  juice  occur- 
ring when  no  ingesta  are  present  in  the  stomach.  Analysis  shows 
that  it  possesses  all  the  properties  of  the  gastric  juice  with  an  excess 
of  free  hydrochloric  acid.  If  no  food  is  given  and  the  stomach  be 
aspirated  before  the  second  attack  of  vomiting  occurs,  at  the  time 
of  appearance  of  pain  and  nausea,  or  if  the  second  vomitus  be  anatyzed 
and  in  either  event  be  found  to  consist  of  a  considerable  quantity  of 
pure  gastric  juice,  the  diagnosis  is  conclusive. 
The  attacks  are  intermittent. 

All  cases  should  be  examined  as  to  motor  functions  and  dilata- 
tion, since  attacks  of  gastrosuccorrhea  occur  with  these  conditions. 
One  should  also  exclude  organic  disease,  such  as  the  gastric  crisis  of 
locomotor  ataxia.  In  the  latter  case  we  have  loss  of  patellar  reflexes, 
the  Argyll-Robertson  pupil,  and  the  Rhomberg  symptom. 

Prognosis. — In  pure  cases  of  gastrosuccorrhea  continua  periodica 
the  prognosis  may  be  fairly  good.  It  is  often  possible  to  lessen  the 
severity  of  the  attacks  or  in  some  cases  even  to  effect  a  cure. 

Treatment. — Prophylaxis. — We  must  first  endeavor  to  find  the 
cause  of  these  attacks,  and  by  correcting  it  prevent  their  recurrence. 
In  the  interval  between  attacks  the  stomach  contents  should  be 
examined  after  a  test  breakfast  or  meal,  and  we  should  determine 
whether  or  not  hyperchlorhydria  exists. 

The  motor  functions  of  the  stomach  should  also  be  carefully 
tested,  and  any  motor  insufficiency  if  present  should  receive  treat- 
ment. If  there  be  excesses  in  smoking  or  drinking,  tobacco  and 
alcohol  should  be  cut  off.  If  there  are  errors  in  diet,  they  should  be 
corrected.  If  mental  overexertion  or  nei-\^ous  excitement  is  a  cause, 
such  conditions  should  be  corrected.  If  the  patient  is  neurasthenic, 
he  should  receive  careful  treatment.  Hygienic  method  of  living, 
exercise  out  of  doors,  horseback  riding,  golf,  etc.,  are  ser\'iceable. 

Treatment  of  the  Attack. — During  the  early  stage,  when  the  pain 
and  nausea  first  begin,  binding  the  free  acid  with  the  whites  of  several 
raw  eggs  beaten  up  in  water  or  in  milk,  or  the  use  of  B  j  to  ij  (30.0-60.0) 
of  10  per  cent,  gelatin,  or  neutralizing  the  acid  by  the  administration 
of  an  alkaH,  such  as  oss  to  j  (2.0-4.0)  sodium  bicarbonate  in  water, 


FUNCTIONAL   DISEASES   OF   THE   STOMACH  295 

Siv  (125.0),  or  Vichy;  or  milk  of  magnesia,  oss  (16.0),  or  magnesia 
usta,  oss  to  j  (2.0-4.0) ,  will  at  times  mitigate  the  symptoms.  Einhorn 
recommends  a  large  dose  of  bromid  at  the  appearance  of  the  first 
symptom  and  claims  that  it  will  often  cut  the  attack  short  or  lessen  its 
severity.  About  gr.  15  to  30  (1.0-2.0)  of  sodium  bromid  should  be 
given,  preferably  in  Vichy  (an  alkali). 

The  patient  should  be  kept  recumbent,  with  the  application  of 
moist  heat  or  dry  heat  (wet  hot  flannel  compress  or  hot-water  bag) 
applied  to  the  gastric  region.  He  will  generally  vomit  in  spite  of 
treatment. 

The  best  method,  I  believe,  is  to  perform  lavage  early,  not  waiting 
until  vomiting  occurs,  if  the  pain  and  nausea  are  not  relieved  by 
administration  of  the  albuminous  food  or  alkalis. 

Wash  the  stomach  thoroughly  with  an  alkaline  solution — i  to  2 
quarts  (liters)  of  warm  water  in  which  Bij  to  iij  (30.0-45.0)  of  milk 
of  magnesia  (Phillips)  have  been  dissolved — or  oss  (16.0)  of  sod. 
bicarb,  or  oSS  (16.0)  of  magnesia  usta.  Before  withdrawing  the 
tube  after  lavage,  pour  through  it  into  the  stomach  3ij  (8.0)  of  milk 
of  magnesia  dissolved  in  oij  (30.0)  of  water,  to  which  is  added  TTLx 
(0.6)  tincture  of  belladonna  to  check  further  secretion.  Sod.  bicarb., 
3j  (4-0),  may  be  substituted  for  the  magnesia. 

If  the  pain  is  very  severe  it  may  be  necessary  to  give  one  or 
several  hypodermics  of  morphin,  gr.  ^  to  ^  (0.008-0.016),  preferably 
combined  with  atropin,  gr.  ^-^o  to  j^-q  (0.00032-0.00065),  which  last 
is  of  value  to  lessen  h^^persecretion.     Codein  may  be  employed. 

To  the  use  of  cocain  for  nausea  and  vomiting  I  am  opposed.  It 
gives  but  temporary  relief,  is  a  marked  cardiac  depressant,  many 
patients  have  an  idiosyncrasy  to  even  a  small  amount,  and  there  is 
danger  of  the  cocain  habit. 

It  may  be  necessary  to  repeat  lavage  several  times.  The  bella- 
donna or  atropin  should  be  pushed  to  physiologic  limits,  with  dilata- 
tion of  the  pupils  and  dryness  of  the  throat,  if  one  expects  to  have 
any  effect  in  checking  the  hypersecretion. 

Some  recommend  washing  the  stomach  with  i :  2000  silver  nitrate 
solution,  and  following  it  with  plain  warm  water. ' 

Some  patients  will  not  consent  to  lavage,  and  in  these  cases 
we  can  simply  give  internally  several  large  doses  of  the  alkalis 
with  belladonna  every  two  to  three  hours,  whether  they  vomit 
or  not. 

If  there  is  great  thirst,  a  glass  of  hot  water  in  which  sodium  bicar- 
bonate, oj  (4-0),  has  been  dissolved  is  of  service,  if  taken  in  small 
amounts  (teaspoonful  doses).  It  often  relieves  the  nausea  and  the 
alkali  is  of  value;  or  a  small  piece  of  cracked  ice  or  an  occasional 
teaspoonful  of  cool  water  can  be  also  employed. 

The  raw  white  of  eggs  beaten  up,  placed  in  a  cup  and  packed 
around  with  ice,  or  the  5  to  10  per  cent,  gelatin,  two  teaspoonfuls 
given  every  half -hour  or  so,  both  relieves  thirst  and  binds  the  acid;  or 


296  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Milk Sviij  (250CC.)  1  Pack     this 

Oxalate  of  cerium gr.  x  (0.6)  \  dissolved  >    -^  ^^^ 

Sodium  bicarbonate gr.  15  to  3ss  (1.0-2.0)  J    therein.  J 

Give  I  teaspoonful  (4.0)  every  half -hour  or  so  as  to  relieve  thirst  and  bind 
the  acid,  and  check  nausea  and  vomiting. 

In  some  cases  rectal  enemata  of  hot  normal  salt  solution  at  11 5  °  F. , 
Oj  (500  cc),  relieve  thirst  and  stimulate  the  pulse.  It  may  be 
necessary  to  employ  smaller  quantities  of  saline  solution  or  to  use 
proctoclysis. 

It  is  best  for  the  patient  not  to  drink  too  much  the  first  day  of 
the  attack,  except  the  remedies  noted,  as  an  excessive  amount  of 
fluid  favors  vomiting.  No  food  should  be  given  except  as  above 
advised.  On  the  next  day  small  quantities  of  milk  diluted  with 
lime-water  or  matzoon  and  Vichy  or  albumen-water  can  be  given, 
oss  to  j  (16.0-32.0),  every  hour,  and  the  gelatin  can  be  kept  up. 

The  quantity  of  nourishment  may  then  gradually  be  increased 
and,  finally,  soft-boiled  eggs,  scraped  raw  meat,  and  a  subsequent 
diet  such  as  is  used  in  hyperchlorhydria. 

The  bowels  should  be  moved  early  in  the  attack  by  a  soapsuds 
enema,  i  quart  (hter),  to  which  oviij  (250  cc.)  olive  oil  have  been 
added,  or  by  enteroclysis. 

To  recapitulate.  In  the  treatment  of  the  acute  attack  I  follow 
out  the  following  method :  Heat  to  the  abdomen,  the  administration 
at  once  of  an  alkali  by  mouth ;  the  bowels  are  moved  by  enema,  and 
the  stomach,  after  a  brief  period  of  rest,  washed  with  an  alkali,  pref- 
erably with  milk  of  magnesia;  oij  (8.0)  of  milk  of  magnesia  diluted 
with  water  oiv  (125  cc),  with  tincture  of  belladonna,  TTlx  (0.6),  being 
poured  into  the  stomach  through  the  tube  before  removal.  A  hypo- 
dermic of  morphin  is  then  given,  the  room  darkened,  and  the  patient 
kept  perfectly  quiet.  This  treatment  is  repeated  if  necessary.  If 
the  patient  will  not  consent  to  lavage,  then  alkalis,  gelatin  and  whites 
of  raw  eggs  with  belladonna  should  be  administered. 

GASTROSUCCORRHEA  (CONTINUA  CHRONICA) 

(Synonyms. — Chronic  Gastrosuccorrhea;  Chronic  Hypersecretion;  Chronic 
Parasecretion ;  Chronic  Continuous  Secretion  of  Gastric  Juice;  Reichmann's 
Disease.) 

Chronic  continuous  secretion  of  the  gastric,  juice  is  a  per\^ersion 
of  function  which  is  characterized  by  the  secretion  of  an  excessive 
quantity  of  gastric  juice,  not  only  after  the  ingestion  of  food  but  also 
when  the  stomach  is  ernpty. 

The  chief  diagnostic  point  is  the  secretion  of  large  quantities  of 
gastric  juice  in  the  fasting  stomach.  Reichmann,^  in  1882,  was  the 
first  to  describe  this  condition. 

1  Berlin,  klin.  Wochenschr.,  1882,  No.  40. 


FUNCTIONAL    DISEASES    OF    THE    STOMACH  297 

We  must  make  a  distinction  between  the  pure  cases  of  chronic 
gastrosuccorrhea  and  those  in  which  dilatation  (atonic)  of  the  stomach 
or  dilatation  from  stenosis,  especially  with  ulcer,  exist,  and  with 
which  hypersecretion  is  an  associated  symptom. 

After  fasting,  small  quantities  of  gastric  juice,  as  much  as  5  to 
10  cc.  or  15  to  20  cc,  on  one  or  two  occasions  have  been  aspirated. 
Thus  the  possibility  of  a  normal  small  secretion  may  exist.  If, 
however,  we  find  20  to  30  cc.  or  more  of  gastric  juice  constantly  in  the 
stomach  of  a  patient  who  has  been  fasting  for  some  time,  the  finding 
we  would  consider  to  be  pathologic  and  to  be  an  evidence  of  con- 
tinuous hypersecretion. 

Frequency. — Cases  of  pure  gastrosuccorrhea  chronica  without 
any  associated  organic  lesions  of  the  stomach  I  believe,  with  Einhorn, 
to  be  quite  a  rare  disease,  while  those  found  in  association  with 
ectasia  are  not  uncommon.  Undoubtedly  the  latter  class  have  been 
confused  with  the  pure  cases.  Chronic  hypersecretion  is  more  rare 
than  the  periodic  type. 

Etiology. — Chronic  hypersecretion  occurs  more  frequently  in 
men  than  women,  and  in  youth  and  middle  life. 

Severe  mental  strain  or  worry  seem  to  be  factors,  also  the  neurotic 
condition. 

The  periodic  type  may  develop  into  the  chronic;  persistent 
hyperchlorhydria  or  its  causes,  such  as  indigestible  or  irritating  food 
or  condiments,  the  abuse  of  alcohol  or  tobacco,  or  excessive  hot  or 
cold  food  and  drinks,  may  be  factors. 

Dilatation  of  the  stomach,  ulcer,  or  tetany  may  have  chronic 
gastrosuccorrhea  associated  with  them. 

Symptoms. — In  most  of  the  cases  the  patients  state  that  the  gas- 
tric symptoms  began. gradually,  a  feeling  of  pressure,  fulness,  and  sour 
eructation  commencing  a  couple  of  hours  after  the  ingestion  of  food, 
resembling  the  symptoms  of  hyperchlorhydria.  Then  pain  occurs 
several  hours  after  meals  or  shortly  before  the  ensuing  meal;  it  is 
most  frequent  on  the  empty  stomach,  just  before  the  next  meal  is  due. 
It  ma}^  be  spasmodic  in  character ;  nausea  and  then  vomiting  follows. 
The  vomiting  may  increase  in  frequency  and,  finally,  occur  several 
times  a  day  after  breakfast  and  supper.  In  some  cases  the  attacks 
take  place  during  the  night  between  12  and  2  o'clock,  the  patient 
being  awakened  by  burning  and  pain  in  the  epigastrium,  acid  eructa- 
tions, and,  finally,  vomiting  of  very  acid  fluid  takes  place;  after 
vomiting  the  pain  is  relieved.  The  night  vomitus  is  generally  a  clear 
fluid.  Albuminous  food,  egg  or  milk,  will  often  relieve  the  pain. 
The  day  vomitus  is  very  acid  (quite  liquid),  but  some  food  is  mixed 
with  it;  is  often  of  a  grass-green  color. 

The  appetite  is  generally  good  and  often  increased.  Sometimes 
the  patient  develops  excessive  hunger ;  loss  of  appetite  is  rather  rare. 

Thirst  is  increased,  the  bowels  are  constipated,  the  urine  dimin- 
ished and  less  acid  than  normal. 


298  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

There  may  be  some  loss  of  weight,  but  no  marked  emaciation. 

The  contrast  between  the  physical  condition  of  the  pure  type  of 
chronic  hypersecretion  and  that  in  which  dilatation  of  the  stomach 
accompanies  it  will  be  described  under  Differential  Diagnosis. 

Palpation. — The  stomach  is  more  or  less  sensitive  to  pressure. 

Diagnosis. — The  diagnosis  of  gastrosuccorrhea  continua  chronica 
can  onlv  be  made  hy  examination  of  the  stomach  in  the  fasting  condi- 
tion. To  exclude  error,  the  method  suggested  by  Reichmann  is 
the  best. 

The  stomach  should  be  thoroughly  washed  out  with  warm  water, 
preferably  at  night,  all  food  and  drink  should  be  withheld  for  ten  to 
twelve  hours,  and  then  aspiration  of  the  stomach  contents  should  be 
performed.  Anywhere  from  50  to  125  cc.  of  gastric  contents  is  thus 
obtained.  This  secretion  exhibits  all  the  properties  of  the  gastric 
juice.  It  contains  no  particles  of  food.  The  fluid  is  usually  watery 
and  clear  in  color  or  it  may  be  yellowish  green  from  admixture  with 
bile.  There  is  an  increased  degree  of  acidity,  the  values  for  free 
hydrochloric  acid  being,  as  a  rule,  pretty  high.  There  are  no  starchy 
products  contained  therein.  There  are  no  evidences  of  fermentation 
and  no  organic  acids  present.  Under  the  microscope  no  sarcinae 
are  found. 

An  hour  after  Ewald's  test  breakfast  more  liquid  than  usual  is 
present  and  the  acidity  is  quite  high  (75  to  125),  higher  than  when 
the  fasting  contents  are  aspirated.  A  thin  disk  of  egg-albumen  will 
be  digested  at  blood  temperature  in  an  hour  or  so.  Lugol's  solution 
gives  a  blue  or  violet  reaction,  showing  the  starch  is  unchanged  or 
slightly  so. 

Three  to  four  hours  after  Riegel's  test  dinner  hardly  any  meat 
fibers  are  found,  whereas  considerable  starchy  material  is  present. 
The  acid  content  is  high  and  the  residue  considerable. 

We  must  remember  that  the  above  description  is  a  case  of  pure 
chronic  gastrosuccorrhea,  in  which  there  is  no  motor  insufficiency. 
These  cases  I  believe  to  be  quite  rare. 

Differential  Diagnosis. — Many  of  our  writers  do  not  properly 
distinguish  between  cases  of  pure  chronic  hypersecretion  and  those 
in  which  dilatation  of  the  stomach  is  a  complication.  The  examina- 
tion of  the  stomach  as  regards  its  size,  position,  and  motor  functions 
should  always  be  carried  out,  and  this  will  aid  us. 

Ulcer  of  the  stomach  may  be  complicated  by  hypersecretion,  and 
in  a  few  rare  cases  gastric  tetany  is  associated  with  it.  Occasionally 
no  symptoms  pointing  to  a  previous  ulcer  can  be  obtained,  though 
there  may  have  been  a  previous  history  of  hyperchlorhydria,  and 
at  subsequent  operation  the  stenosis  will  be  found  to  be  due  to  an 
ulcer  not  entirely  healed. 

In  ectasy  from  pyloric  benign  stenosis  with  hypersecretion  we 
have  excessive  vomiting  of  a  large  quantity  of  greenish-yellow  fluid, 
pain,  cramp-like  attacks,  peristaltic  unrest,  excessive  thirst,  marked 


FUNCTlONAIv   DISEASES    OF   THE   STOMACH  299 

loss  of  weight,  skin  over  the  abdomen  dry  and  wrinkled,  loss  of 
weight  which  is  often  very  great,  and  occasionally  some  tinge  of 
blood  in  the  vomitus.  The  patient  presents  almost  a  cachectic 
appearance,  and  there  is  in  some  patients  the  sense  of  resistance,  or 
even  a  feeling  of  thickening  at  the  pylorus. 

The  vomitus  or  contents  aspirated  after  a  test  meal  will  separate 
into  three  layers:  an  upper  layer  of  foam,  middle  layer  yellow  or 
yellowish  green,  and  a  lower  layer  of  sediment.  Meat  is  digested,  the 
sediment  consists  of  starchy  material.  Acidity  is  markedly  increased 
and  content  of  hydrochloric  acid  is  high.  Pepsin  digestion  is  rapid. 
Starchy  materials,  yeast-cells,  and  sarcinge  are  found  under  the 
microscope. 

Examination  further  shows  marked  dilatation  of  the  stomach, 
with  great  relative  motor  insufficiency.  Hyperchlorhydria  with 
atonic  dilatation  must  also  he  differentiated.  The  pain  and  vomiting 
present  some  of  the  symptoms  of  hypersecretion. 

For  example,  in  one  case  a  test  meal  given  at  night  shows  a.  m. 
on  aspiration  500  cc.  of  contents;  separating  into  three  layers,  fermen- 
tation being  present,  stomach  one  finger  below  umbilicus.  Reich- 
mann's  method  was  then  employed,  i.  e.,  the  stomach  was  thoroughly 
washed  out  and  nothing  given  for  twelve  hours.  Morning  aspiration 
showed  the  organ  to  be  empty,  no  secretion,  hence  the  diagnosis  was 
clear. 

In  many  cases  of  marked  stagnation  of  the  stomach  contents 
with  dilatation,  continuous  secretion  may  be  simulated.  The 
method  of  testing  the  empty  stomach  will  determine  the  diagnosis. 

If  there  have  been  hematemesis,  melena,  circumscribed  tenderness, 
or  dorsal  tenderness  ulcer  will  be  suspected.  Frequent  examinations 
for  occult  blood  in  the  stomach  contents  and  stool  are  of  service. 

Tetany  may  complicate  hypersecretion  with  dilatation.  The 
symptoms  are  characteristic. 

Prognosis. — In  the  cases  of  pure  chronic  hypersecretion  the 
prognosis  is  fairly  good.  Most  patients  improve  under  treatment, 
but  quite  frequently  there  are  relapses.  Sometimes  the  condition 
persists  for  years.  Hypersecretion  pei'  se  is  never  fatal.  When 
complications  such  as  dilatation  of  the  stomach  are  present  the 
serious  features  are  dependent  on  them. 

Treatment. — Prophylaxis. — The  patient  should  not  overwork, 
should  be  relieved  of  all  mental  oxerexertion,  and  lead  a  rational 
out-of-door  life,  with  proper  attention  to  exercise  and  hygiene. 
Nervous  conditions  when  present  should  be  treated.  The  patient 
should  avoid  bolting  his  food,  should  not  eat  any  irritating  sub- 
stances, such  as  mustard,  pepper,  spices,  alcohol,  and  verv  hot  and 
very  cold  food  and  drink;  in  fact,  he  should  avoid  everything  that 
will  overstimulate  the  secretion  of  gastric  juice. 

Albuminous  food  is  digested  well,  and  starchy  food,  badl)^;  hence 
the  latter  should  be  reduced  in  quantity. 


300  DISEASES   OP  THE   STOMACH   AND  INTESTINES 

Diet. — This  is  practically  the  same  as  in  hyperchlorhydria,  except 
that  very  large  quantities  of  fluid  should  be  avoided. 

If  the  appetite  and  physical  condition  are  good,  it  is  just  as  well 
to  give  but  three  meals  a  day,  so  as  to  give  the  stomach  a  rest  and 
not  tend  to  keep  up  gastric  secretion.  In  this  event  the  excessive 
acidity  can  be  neutralized  between  feedings  by  alkalis.  Doses, 
5ss  to  j  (2.0-4.0)  of  magnesia  usta,  milk  of  magnesia,  or  soda  bicarb, 
should  be  given,  as  in  hyperchlorhydria,  in  water  one  to  two  hours 
after  meals,  and  the  hypersecretion  and  the  pain  relieved  by  tincture 
of  belladonna,  TTLx  (0.6),  t.  i.  d. 

On  the  other  hand,  some  patients,  as  in  hyperchlorhydria,  readily 
feel  satiated,  and  yet  desire  food  frequently.  They  may  also 
be  losing  some  weight,  especially  in  the  cases  complicated  with 
dilatation;  small  meals,  which  are  readily  expelled  from  the 
stomach  {i.  e.,m  soluble  form  or  mushes),  must  be  given,  and  yet 
the  nutrition  must  be  kept  up,  which  last  necessitates  frequent 
feeding. 

The  diet,  for  example,  when  given  in  small  frequent  meals  would 
be  as  in  hyperchlorhydria,  but  less  fluid: 

7.30  A.  M. — Milk  or  cocoa,  250  cc.  (oviij),  2  zwieback  or  toast  and  egg  (i). 
10.00  A.  M. — Beef  sandwich  or  ham  sandwich. 
1.30  p.  M. — Soup,  250  cc.  (oviij),  with  raw  egg,  steak  (gm.  100),  potatoes 

(gm.  50). 
4.00  p.  M.' — Same  as  10  a.  m. 
7.00  p.  M. — 2  eggs  or  meat  (gr.  100),  2  slices  toast,  butter  (gm.  20). 

If  there  is  dilatation,  more  soluble  food  should  be  given  (see 
Dilatation  of  the  Stomach).  Starches  should  be  given  thoroughly 
cooked,  or  predigested  and  in  small  amounts,  and  preferably  in 
soups  and  mushes;  potatoes  should  be  mashed  and  alcohol  avoided; 
also  avoid  cabbage,  turnips,  spices,  pickles,  mustard,  etc. 

Medicaments.— ^ To  lessen  hypersecretion, 

Tinct.  belladonna  in  doses  of  TTLx  (0.6)  or  more,  t.  i.  d.  before 
meals,  up  to  physiologic  effects,  or  ext.  belladonna,  gr.  |  to  |  (.01- 
.02),  will  lessen  secretion  and  subsequent  hypersecretion.  Atropin, 
gr.  TW  to  5^0  (0.0006-0.0013)  t.  i.  d.,  by  mouth  or  hypodermic, 
is  also  of  value ;  the  pain  and  the  spasm  of  the  pylorus  and  the  hy- 
persecretion are  lessened  by  these  remedies. 

One  can  administer  a  large  dose  of  belladonna  after  lavage  before 
withdrawing  the  tube.  Bismuth  subnitrate,  gr.  30  (2.0)  in  Sij  (60.0) 
water,  t.  i.  d.  half  an  hour  before  meals,  or  olive  oil,  oj  (30.0),  t.  i.  d. 
before  meals,  or  the  latter  containing  gr.  30  (2.0)  of  bismuth  lessen 
secretion. 

Large  doses  of  morphin,  as  have  been  recommended,  I  believe 
to  be  a  pernicious  method  for  obvious  reasons. 

For  Attacks  of  Pain. — Alkalis,  such  as  milk  of  magnesia  (Phillips), 
5ss  (16.0)  in  oij  (60.0)  of  water,  or  magnesia  usta,  5j  (4-0).  or  soda 
bicarb,  alone,  oj  (4-0),  or  combined  with  the  above,  are  of  ser\dce. 


FUNCTIONAL    DISEASES    OF    THE    STOMACH  3OI 

Albumen-water  (white  of  raw  egg)  or  gelatin,  5  to  10  per  cent,  solution 
(J3 — 30.0),  are  useful.  Heat  should  be  applied  externally.  Lavage, 
preferably  with  an  alkaline  solution,  with  oj  (30.0)  milk  of  magnesia 
in  I  quart  (liter)  of  warm  water,  or  with  soda  bicarb.,  oss  (16.0),  or 
magnesia  usta,  oss  (16.0)  in  the  same  amount  of  water,  is  the  best 
method.  A  small  quantity  may  be  left  in  the  stomach  and  bella- 
donna, TUx  (.06) ,  with  an  additional  dose  of  the  alkali  poured  in  before 
removing  the  tube. 

In  some  cases  it  may  be  necessary  to  administer  a  hypodermic 
of  codein,  gr.  ^  to  ^  (0.0016-0.032),  or  morphin,  gr.  i  to  ^  (0.008- 
0.016).     They  should  only  be  given  by  a  nurse  or  physician. 

Alkalis.— ~1{  there  be  no  ectasy,  a  course  at  Carlsbad  is  of  service, 
or  artificial  Carlsbad  salts  or  the  imported  salts,  or  alkaline  mineral 
waters,  such  as  Vichy,  can  be  taken  at  meals  or  just  before  meals. 
This  lessens  hyperacidity  and  thus  aids  digestion. 

To  prevent  subsequent  attacks  of  pain  an  alkali  should  be  given 
at  the  height  of  digestion,  about  two  to  two  and  a  half  hours  after 
food;  magnesia  usta  or  milk  of  magnesia,  3ss  to  ij  (2.0-8.0),  alone 
or  combined  with  soda  bicarb,  or  ammonia  magnesia  phosp.,  as 
described  under  Hyperchlorhydria,  are  useful. 

Lavage. — Reichmann  and  Riegel  were  the  first  to  recommend 
lavage  for  the  treatment  of  this  condition.  Reichmann  and  Einhorn 
perform  lavage  in  the  morning  with  the  stomach  fasting,  while  Riegel 
washes  it  out  six  or  seven  hours  after  the  heavy  meal.  My  method 
is  entirely  dependent  on  the  time  of  appearance  of  the  symptoms. 
If  the  attack  comes  on  at  midnight  or  early  in  the  morning,  it  seems 
most  logical  to  perform  thorough  lavage  at  bedtime  with  an  alkaline 
solution,  leaving  some  of  it  in  the  organ,  and  also  pouring  into  it  a 
large  dose  of  belladonna — Tllx  to  xv  (0.6-1.0). 

If  the  attacks  come  on  after  breakfast  or  the  noon  meal,  then 
the  early  morning  lavage  on  the  empty  stomach  seems  best.  I  often 
recommend  pouring  Carlsbad  salts  directly  through  the  tube  before 
withdrawal.  With  severe  pain  it  may  be  necessary  to  perform  lavage 
again  during  the  exacerbation. 

If  there  be  dilatation  and  marked  retention  of  food,  lavage  six 
hours  after  the  full  noon  meal  is  necessary,  then  followed  by  a  light 
supper;  an  alkali  and  belladonna  should  be  given  at  bedtime. 

In  some  obstinate  cases  Reichmann  recommends  lavage  with 
1 :  1000  to  1 :  2000  silver  nitrate  solution.  It  is  safest  to  wash  the 
stomach  with  about  500  cc.  of  this  solution,  150  cc.  at  a  time,  and 
then  wash  out  the  stomach  with  warm  water.  Normal  salt  solution 
may  be  substituted  if  there  is  much  irritation.  Some  also  recom- 
mend the  internal  administration  of  gr.  ^  to  ^  (0.011-0.016)  of  silver 
nitrate  in  pure  form  or  in  solution  t.  i.  d.  and  at  bedtime. 

Stomach  Spray. — Einhorn  claims  excellent  results  from  spraying 
the  stomach  with  his  gastric  spray  with  nitrate  of  silver  i :  2000  to 
1 :  1000  after  a  previous  washing  with  warm  water. 


302  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Direct  Galvanization. — The  same  author  reports  good  results 
from  internal  galvanization  of  the  stomach,  employing  it  and  the 
gastric  spray  on  alternate  days.  Riegel  finds  no  benefit  from  intra- 
gastric galvanization  unless  atony  is  present,  and  in  this  I  agree. 

If  the  condition  of  chronic  hypersecretion  be  complicated  by 
dilatation,  this  condition  must  be  treated.  Rose's  belt  is  of  value  for 
atonic  ectasia.  If  there  is  pyloric  stenosis,  gastro-enterostomy  is 
indicated. 

Lavage  with  an  alkali,  belladonna  or  atropin  in  large  doses, 
the  alkaline  treatment,  diet,  and  in  some  cases  spraying  or  lavage 
with  nitrate  of  silver,  are  the  chief  requirements. 


CHAPTER  XV 

DISTURBANCES  OF  THE  MOTOR  FUNCTION  OF  THE 
STOMACH— ACUTE  ATONY— CHRONIC  ATONY- 
ACUTE  DILATATION  OF  THE  STOMACH— CHRONIC 
DILATATION  OF  THE  STOMACH 

ATONY  OF  THE  STOMACH 

Atony  of  the  stomach  may  be  defined  as  a  relaxation  and  weaken- 
ing of  the  muscular  wall  of  the  organ,  so  that  it  cannot  empty  itself 
in  the  normal  time,  and  thus  motor  insufficiency  results.  It  is  a 
perversion  of  motor  function.  With  simple  atony,  the  stomach  is 
of  normal  size,  but  motor  insufficiency  exists.  When  the  organ  is 
enlarged,  we  speak  of  ectasy  or  dilatation,  which  is  combined  with 
motor  insufficiency. 

There  are  two  types  of  atony  of  the  stomach :  First,  acute  atony; 
second,  chronic  atony. 

Acute  Atony  of  the  Stomach 

Acute  atony  of  the  stomach  may  occur  as  a  preliminary  to  acute 
dilatation  of  the  stomach,  just  as  may  chronic  atony  to  chronic 
atonic  dilatation. 

Acute  atony  does  not  necessarily  result  in  acute  dilatation. 

Many  of  the  causes  which  produce  acute  dilatation  are  the  factors 
with  acute  atony,  but  the  stomach  has  not  become  dilated.  The  early 
recognition  of  the  condition  is,  therefore,  important.  The  motor 
insufficiency  which  occurs  with  it  may  also  lead  to  error  in  diagnosis. 
The  condition  takes  place  most  frequently  after  overloading  the 
stomach,  bolting  the  food,  or  indigestible  food,  or  alcohol.  It  may 
complicate  acute  gastritis,  with  belching,  fulness  or  discomfort  in 
the  stomach,  some  distention,  constipation,  and  delayed  vomiting; 
in  fact,  merely  discomfort  for  a  considerable  period  of  time  and  then 
the  vomiting  of  food  taken  some  hours  before.  The  splashing  sound  is 
present.  The  stomach  becomes  distended,  tympanitic,  and  often 
sensitive  to  pressure.  A  sudden  attack  of  retention  of  chyme  for  an 
abnormal  length  of  time  is  the  salient  symptom. 

In  one  case,  because  of  motor  insufficiency  following  a  single 
dietary  indiscretion,  a  diagnosis  of  ectasy  with  motor  insufficiency 
was  made.  Examination  demonstrated  normal  functions,  the 
attack  evidently  being  an  acute  atony  (acute  motor  insufficiency) 
of  temporary  duration. 

303 


304  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

During  typhoid  or  the  infectious  diseases,  gastric  disturbances 
with  belching,  discomfort,  sudden  distention  of  the  stomach,  consti- 
pation, or  diarrhea,  with  delayed  vomiting,  the  vomitus  consisting  of 
milk  (curdled)  or  other  food  taken  some  hours  previously,  are  significant 
of  this  condition.  There  may  be  evidences  in  the  stool  of  nourishment 
taken  forty-eight  hours  before. 

Treatment. — The  immediate  emptying  of  the  gastro-intestinal 
tract  is  the  indication.     Lavage  should  he  performed  at  once. 

A  good  cathartic,  calomel,  gr.  3  to  5  (0.2-0.3),  or  blue  mass, 
gr.  5  (0.3),  followed  by  a  saline  cathartic,  should  be  given. 

Castor  oil,  oj  to  ij  (30.0-60.0),  is  also  excehent.  Enemata,  and 
especially  rectal  irrigation,  are  of  value  to  produce  intestinal  peris- 
talsis. 

Acute  atony  may  progress  rapidly  to  acute  dilatation  or  develop 
more  slowly  for  ten  to  twelve  hours,  and  then,  if  untreated,  result  in 
acute  ectasy.     Its  early  recognition  is,  therefore,  important. 

Chronic  Atony  of  the  Stomach 

{Synonyms. — Motor  Insufficiency;  Gastric  Insufficiency;  ^Nlotor  Insufficiency  of 
the  First  Degree;  Myasthenia  Ventriculi;  Atonia  Gastrica.i) 

Chronic  atony  of  the  stomach,  if  untreated,  may  result  in  the 
atonic  type  of  dilatation  of  the  stomach. 

Its  correction  is,  therefore,  of  great  importance.  We  use  the 
term  "chronic"  in  distinction  from  the  acute,  evanescent  form.  In 
the  pure  cases  no  dilatation  is  present. 

Etiology. — Atony  of  the  stomach  may  complicate  many  digestive 
disorders,  such  as  chronic  gastritis,  hyperchlorhydria,  neurasthenia 
gastrica,  and  diseases  of  the  heart  and  lungs,  as  tuberculosis.  It 
occurs  in  nen."Ous  and  hysteric  subjects  and  may  exist  as  a  primary 
neurosis. 

It  mav  occur  as  a  result  of  biliary  colic  or  the  crisis  of  tabes. 

Symptoms. — If  atony  occurs  as  a  complication  of  some  other 
affection  of  the  stomach,  its  symptoms  will  be  overshadowed  by 
the  primary  disease.  The  characteristic  symptoms  of  atony  are :  a 
feeHng  of  fulness  after  meals,  sHght  distention,  belching  of  gas,  dimi- 
nution of  appetite,  headache,  and  constipation.  The  resulting  motor 
insufficiencv  is  productive  of  fermentation  and  gas  production. 

Physical  Examination. — There  is  generally  some  distention  of 
the  stomach  with  gas.  The  splashing  sound  is  easily  produced  over 
the  greater  part  of  the  stomach  an  hour  or  two  after  the  test  breakfast, 
or  four  or  five  hours  after  a  full  meal.  If  the  splash  extend  to  the 
umbilicus  or  helow  it,  this  is  evidence  that  dilatation  is  associated. 

If  movable  kidney  is  associated,  gastroptosis  is  present.  These 
are  not  pure  cases. 

1  Rose  has  called  to  our  attention  that  atonia  gastrica  is  an  improper  term, 
really  meaning  abdominal  relaxation.  It  is  so  applied  in  our  work  to  define 
splanchnoptosis. 


ATONY   OF   THE    STOMACH  305 

An  hour  after  Ewald's  test  breakfast  aspiration  of  the  stomach 
contents  will  remove  100  cc.  or  more  of  gastric  contents;  an  excellent 
test  taken  in  connection  with  the  symptoms. 

Six  hours  after  Leube's  test  dinner  aspiration  and  lavage  show 
considerable  ch^^me,  150  to  200  cc.  The  fasting  stomach  in  the 
morning  is  found  empty. 

Boas  states  that  on  filling  the  stomach  with  water,  the  greater 
curvature  will  descend  as  water  is  added.  This  is  not  reUable.  The 
lower  border  will  descend  after  a  moderate  amount  of  water,  if  the 
stomach  is  dilated. 

Prognosis. — This  is  good  if  proper  treatment  is  instituted. 

Treatment. — If  hyperchlorhydria  or  chronic  gastritis  is  present, 
each  should  receive  appropriate  treatment;  as  should  tuberculosis, 
endocarditis,  nervous  conditions,  etc. 

In  all  cases  of  chronic  atony  of  the  stomach,  Rose's  plaster  belt 
is  indicated.  Atony  of  the  intestines  is  frequently  associated,  and 
the  use  of  mechanic  support  lends  tone  to  the  general  musculature 
of  the  abdomen,  keeps  the  stomach  well  supported,  and  prevents 
atonic  dilatation  of  the  organ. 

Vibratory  massage  or  massage  over  the  entire  gastro-intestinal  tract 
is  of  value.  It  stimulates  the  muscles  and  lessens  the  tendency  to  con- 
stipation. Outdoor  exercise,  walking,  golf,  and  horseback  riding  are 
indicated.  In  some  cases  douching  the  abdomen  is  of  ser\dce;  in  this 
event  one  must  employ  a  silk  elastic  abdominal  support,  which  can 
be  readily  removed.  I  have  secured  the  best  results  with  Rose's 
belt.  The  patient  should  not  overwork,  either  mentally  or  physically, 
and  should  eat  slowly  and  masticate  the  food  thoroughly;  the  teeth 
should  be  kept  in  good  condition.  An  excessive  quantity  of  fluid 
should  not  be  taken — in  all,  including  water,  soups,  tea,  etc.,  not 
over  I J  Uters  a  day. 

It  is  best  to  give  numerous  divided  meals  of  rather  moderate  size, 
four  or  even  five  daily;  so  as  not  to  overburden  the  stomach  with 
three  large  meals,  and  allow  it  to  thoroughly  empty  itself. 

The  diet  may  include  bread  (fresh  and  hot  breads  are  inter- 
dicted) and  butter,  eggs  in  various  forms,  cereals,  milk,  soup, 
chicken,  steak,  chops,  game,  squab,  fish,  oysters,  and  green  vege- 
tables, which  are  specially  valuable  for  the  constipation;  cocoa, 
weak  tea,  occasionally  weak  coffee,  with  milk  and  sugar.  The  diet 
must  be  modified  if  hyperchlorhydria  or  chronic  gastritis  is  present, 
or  to  suit  the  special  idiosyncrasies  of  the  patient.  Alcohol  should 
be  interdicted. 

Medicaments. — Strychnin  or  nux  vomica  is  of  great  service  to 
tone  up  the  muscular  system.     They  ma}'  be  given  alone,  or 

I^.     Tr.  nucis  vomicae TTtx  (0.59  cc.) 

Comp.  tinct.  cinchona TTtxv  (0.888  cc). — M. 

Sig. — Give  in  a  wineglassful  of  water  t.  i.  d.  half  an  hour  before  meals.  Some 
prefer  it  at  the  same  time  after  meals. 

20 


306  DISEASES   OE    THE    STOMACH   AND   INTESTINES 

or,  if  the  patient  is  anemic,  it  may  be  combined  with  iron  and  arsenic, 
thus: 

I^.     Strych.  sulph gr-  sV  (0.0021) 

Sod.  arsen gr.  -gV  (0.0013) 

Blaud's  iron  pill gr.  v  (0.3). — M. 

One  pill;  administer  t.  i.  d.  after  meals. 

Strych.  sulph.,  gr.  ^0  to  3^0  (0.00x08-0.021),  is  excellent,  or  tinct. 
nux  vomicae  in  combination  with  fluidextract  of  condurango,  or  comp. 
tincture  of  cinchona,  thus: 

I^.     Tinct.  nucis  vomicae, 

Fluidext.  condurango aa  125  cc.  (about  Bij). — M. 

Dose,  20  drops  in  water,  t.  i.  d.  before  meals. 

If  hyperchlorhydria  is  present,  I  omit  strychnin;  though  Musser 
advocates  nux  in  the  neurotic  type. 
Other  useful  iron  preparations  are : 

Iron  tropon 0 j  to  ij  (4.0-8.0),  t.  i.  d. 

Peptomangan  (Gude) 5j  to  iij  (4.0-12.0),  t.  i.  d. 

To  be  given  in  water  or  milk  after  meals. 

Electricity. — This  is  of  service  applied  by  the  external  method  or, 
in  some  cases,  by  intragastric  faradization. 

Static  electricity  or  the  high-frequency  current  may  be  useful  in 
nervous  cases. 

Lavage  is  not  indicated. 

Massage  or  vibratory  massage  is  especially  useful. 

For  Constipation. — The  green  vegetables,  brown,  rye,  and  Graham 
bread,  and  raw  or  stewed  fruits  are  serviceable.  A  glass  of  water 
should  be  taken  on  rising.  The  patient  should  accustom  himself  to 
go  to  stool  at  a  definite  hour,  and  on  the  closet  may  gently  massage 
the  stomach  and  bowels  to  aid  action. 

A  small  gluten  or  glycerin  suppository,  or  the  injection  of  i  ounce 
(30.0)  of  olive  oil,  or  4  to  6  ounces  (125-185  cc.)  of  warm  water  have 
a  good  effect  in  exciting  peristalsis;  or  a  soapsuds  enema,  but  never  of 
larger  size  than  i  liter  (quart).  Olive  oil  injection,  i  pint  to  i  quart 
(500  cc.  to  I  Hter),  at  bedtime,  to  be  retained,  is  useful. 

It  may  be  necessary  to  employ  medication,  such  as  extract  of 
cascara,  gr.  i  to  4  (0.065-0.26) ,  at  bedtime,  or  fluidextract  of  cascara, 
5j  to  ij  (4.0-8.0),  or  pills,  such  as  the  lapactic,  aloin,  belladonna, 
podophylhn,  phenolax,  purgen  tablets,  etc. 

ACUTE  DILATATION  OF  THE  STOMACH 

Acute  dilatation  of  the  stomach  may  be  defined  as  acute  atony 
of  the  stomach,  with  resulting  acute  motor  insufficiency,  gradually 
merging  into  a  paralytic  condition,  and  accompanied  by  a  distention 
of  the  organ  to  beyond  its  normal  physiologic  limits.     Its  lower 


ACUTE    DILATATION    OF   THE    STOMACH  307 

border  extends  to  the  umbilicus  or  usually  to  below  this  point,  and 
the  stomach  may  even  occupy  the  entire  abdominal  cavity. 

Brunton,  Fagge,  Boas,  Hemmeter,  notably  Campbell  Thomson,^ 
and  Lewis  A.  Conner,^  have  written  on  this  subject.  The  fatal  or 
most  severe  cases  have  been  reported,  but  the  condition  occurs  quite 
frequently.  I  have  already  referred  to  numerous  types.''  Personal 
investigation  demonstrates  that  five  anatomic  types  of  acute  ectasy 
exist: 

1.  Acute  dilatation  of  the  stomach  alone. 

2.  Acute  ectasy,  which  supervenes  on  an  existing  chronic  dilata- 
tion (due  to  stenosis  of  the  pylorus).      Thomson  also  reports  one  case. 

3.  Acute  dilatation  of  the  stomach  and  duodenum,  the  most 
fatal  type. 

4.  Acute  dilatation  of  the  stomach  engrafted  on  chronic  atonic 
dilatation. 

5.  Acute  dilatation  of  the  stomach  and  intestines,  a  mixed  t^^pe, 
so-called  acute  tympanites. 

This  last  is  quite  common,  especially  in  the  acute  infectious 
diseases,  such  as  typhoid  fever  and  pneumonia. 

For  a  complete  description  of  the  theories  of  its  mechanism  and  of 
the  subject,  I  refer  my  readers  to  the  "American  Journal  of  Surgery, " 
November-December,  1908.  Weston  and  the  author  found  that  the 
fibrous  attachment  of  the  transverse  duodenum  to  the  diaphragm 
(muscle  of  Treitz)  and  the  pressure  of  the  dilated  stomach  on  the 
transverse  duodenum  were  chief  factors  in  the  production  of  the  gas- 
troduodenal  type  of  dilatation.  Mesenteric  traction  was  chiefly  pro- 
duced b}^  the  downward  pressure  of  the  stomach  on  the  intestines, 
which  last  exercised  a  countertraction  against  the  muscle  of  Treitz. 
The  collapsed  intestines  were  the  result  of  pressure. 

Mechanism  of  the  Production  of  Acute  Dilatation  of  the  Stomach. 
— The  nature  of  the  condition  as  stated  is  undoubtedly  an  acute  atony, 
with  acute  motor  insufficiency ,  finally  merging  into  a  paralytic  con- 
dition. Many  factors  in  the  production  of  acute  dilatation  have  been 
described,  namely: 

1.  Section  of  the  vagi — by  Carion  and  Hallion — producing  acute 
dilatation  of  the  stomach,  thus  demonstrating  that  an  injury  or  in- 
flammation of  these  nerves  may  be  a  cause,  as  in  cerebral  injury,  or 
pneumonia  at  the  base. 

2.  Injury  to  the  dorsal  spine  by  stimulation  of  the  inhibitory 
nerves. 

3.  Direct  action  of  the  agent  on  the  musculature  or  its  terminal 
nerve  filaments;  among  such  maybe  chloroform,  anesthesia,  toxemia 
from  fermentation,  etc. 

4.  Traumatism. 

^  Brochure. 

2  Am.  Jour,  of  the  Med.  Sci.,  March,  1907. 

^Medical  News,  August  6,  1904. 


3o8 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


/\formoe_ 


5.  Spasmodic  stenosis  of  the  pylorus,  due  to  fermentation  or  hy- 
peracidity. 

6.  Acute  gastrorrhea  (]\Iorris) ;  or  possibly  acute  gastrosuccorrhea 
(Kemp) . 

7.  Kelling's  and  Conner's  experiments  on  spasmodic  closure  of 
the  cardia,  and  the  demonstration  of  kinks  in  various  parts  of  the 
duodenum,  or  of  spasm  of  the  pylorus. 

8.  Rotation  of  the  pylorus. 

9.  Kelling's  and  Braun's  experiments  demonstrating  that  acute 
dilatation  of  the  stomach  is  a  paralytic  condition,  by  producing  it 
with  animals  under  deep  narcosis. 

ID.  Rotation  at  junction  of  cardia  and  esophagus. 
II.  Toxemia  from  infection,  as  from  the  toxins  of  typhoid,  pneu- 
monia, etc, ;  or  auto-intoxication  from  improper  diet,  causing  gastro- 
intestinal dilatation  during  the  course  of  these  diseases.     Dietary  in- 
discretions are  the  causes  of  acute  ectasy  of  the  milder  types  which  I 

shall  shortly  describe. 

12.  Obstruction  of  the  transverse 
duodenum  is  one  of  the  frequent 
causes  so  far  found  in  the  fatal  cases, 
producing  acute  gastroduodenal  di- 
latation, the  most  dangerous  type. 
There  are  a  number  of  causes  given 
for  this  condition,  notably: 

(a)  ]\Iesenteric     obstruction    of 
the  duodenum  from  mesenteric  trac- 
tion.    Out  of  69  fatal  cases  19,  or 
27.5   per  cent.,  Conner  states  were 
caused    by   this,    and   probably   33 
to  50  per  cent,   is  nearer  the  fig- 
ure,   according    to    his    view.     Al- 
brecht    first    called     attention     to 
this  condition,  performing   numer- 
ous experiments. 
{b)  Pressure  from  the  distended  stomach  on  the  transverse  duo- 
denum, producing  complete  obstruction,  is  most  frequently  the  cause 
in  m}^  belief. 

(c)  The  firm  fibrous  band  (muscle  of  Treitz)  attaching  the  trans- 
verse duodenum  to  the  crus  of  the  diaphragm,  a  factor  hereafter  noted 
and  demonstrated  by  Dr.  Weston  and  myself,  is  also  an  important 
factor. 

Regarding  mesenteric  traction,  Conner  further  believed  that  the 
conditions  essential  for  this  were  the  dorsal  position,  an  empty  intes- 
tine, and  a  mesentery  of  such  length  that  the  intestine  can  slip  into 
the  pelvis  and  yet  hang  free.  He  believes  fasting,  purges,  and  enemas 
after  operation  have  a  possible  bearing. 

Accessory  factors  are  suggested,  such  as  a  lax  abdominal  wall, 


Fig.  140. — Experiment:  Acute  dila- 
tation by  CO2  distention. 


ACUTE    DILATATION    OF   THE    STOMACH  309 

pressure  from  weight  of  hepatized  lungs  (in  pneumonia),  coughing 
and  laughing  paroxysms,  lordosis,  or  an  abnormal  position  of  the  duo- 
denum. It  generally  crosses  the  third  lumbar  vertebra ;  the  fourth  is 
the  most  prominent,  and  more  pressure  would  be  exercised  at  this 
point. 

Clotted  blood  behind  the  transverse  duodenum  was  a  cause  in  one 
case. 

On  the  other  hand,  some  believe  the  stomach  dilatation  is  the 
primary  factor  and  the  mesenteric  constriction  is  produced  second- 
arily bv  the  stomach  forcing  down  the  intestines. 

T.  Satterthwaite  and  the  author  studied  the  effects  of  acute 
gastric  distention  on  the  pulse  and  respiration  by  artificially  dis- 
tending the  stomachs  of  patients  with  carbonic  acid  gas  and  taking 
the  blood-pressure  before,  during,  and  after  the  experiment.  In 
Fig.    140  is  illustrated  the  result  in  one  of  our  cases. 

Physician Position  dorsal. 

Pulse.  Pressure.  Respiration.  Pulse. 

Before  distention 72  135  18  Slightly    irritable   (to- 

bacco;. 

After  distention 86  1 20  24         Irregular  in  force ;  some 

intermission  in  the 
beats. 

Pain  under  the  sternum  and  over  the  abdomen,  sensation  of 
suffocation  and  of  flushing  of  the  face,  nausea,  and  discomfort 
accompany  the  acute  distention.  The  stomach  extends  to  one 
finger-breadth  below  the  umbilicus;  in  all  a  distention  of  3^  fingers- 
breadth. 

Aspiration  of  the  contents  relieved  the  symptoms.  These  facts 
emphasize  the  danger  of  overdistention  of  the  stomach  with  carbonic 
acid  gas  for  testing  the  position  of  the  organ  in  patients  with  car- 
diac or  pulmonary  disease  or  in  old  age;  also  the  danger  of  acute 
ectasy  as  a  complication.  ^Moreover,  the  true  dimensions  of  the 
stomach  may  not  be  obtained  by  the  method  of  carbonic  acid  gas 
distention. 

Etiology  of  Acute  Ectasy, — It  may  be  primary  or  secondary. 
The  causes  are  as  follows:  Indigestible  food;  infectious  diseases,  such 
as  typhoid,  pneumonia,  acute  tuberculosis,  and  scarlatina;  during 
convalescence  from  long-continued  disease,  as  chronic  tuberculosis, 
hip-disease,  pneumonia,  typhoid,  sarcoma,  and  anemia;  injury  to  the 
head  or  spine;  traumatism  to  the  abdomen;  postoperative,  in  which 
manipulation  of  the  viscera,  shock,  uremia,  sepsis,  and  the  anesthetic 
are  factors;  one  case  after  gastro-enterostomy  reported  by  the 
author;  retroperitoneal  abscess;  disease  and  deformity  of  the  spine, 
lordosis,  etc. ;  application  of  plaster  jacket  in  spinal  deformity ;  par- 
oxysm of  laughing  supposedly  (true  cause  undiscovered).  Toxemia 
or  auto-intoxication  are,  therefore,  factors  in  many  cases. 


3IO 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


Age. — It  may  6ccur  from  infancy  to  old  age.  Three-fourths  of 
the  cases  are  developed  during  adolescence  or  early  adult  life  (ten  to 
forty  years). 


-  Aforatal  "Position 
./^cuM  Dilatation 


Fig.  141. — Acute  dilatation  of  the  stomach  during  epileptic  attack. 

Sex. — ^Is  about  equally  divided. 

Clinically,  we  may  classify  acute  dilatation  of  the  stomach  into 
cases  presenting  various  clinical  types,  in  this  sense  atypic,  and  into 
the  typic  cases,  which  are  usually  described. 


Fig.  142. — Acute  dilatation  of  the  stomach  in  migraine,  August  29,  1902. 
Borders  of  stomach:  i,  August  16;  2,  August  29,  in  the  morning;  3,  August  29, 
in  the  evening;  4,  August  30,  in  the  morning;  5,  August  30,  in  the  evening; 
6,  August  31,  in  the  morning. 

Clinical  Types  of  Acute  Ectasy. — I  shall  briefly  refer  to  these 
cases,  which  have  already  been  fully  reported  by  me.* 
1  American  Journal  of  Surgery,   Nov.-Dec,   1908. 


ACUTE    DILATATION    OF    THE    STOMACH 


311 


I .  Cases  of  A  cute  Dilatation  of  the  Stomach  with  Symptoms  Pointing 
to  the  Nervous  System. — Convulsions  in  Infants  and  Young  Children. — 
Auto-intoxication  is  the  cause.  I  have  seen  a  case  in  an  infant  two 
years  of  age  in  which  the  stomach  extended  2  inches  below  the 
umbiHcus.  Vomiting  of  bread  and  curds  occurred,  with  immediate 
cessation  of  convulsions  and  return  of  the  stomach  to  normal  position. 
Repeated  attacks  may  lead  to  chronic  ectasy  or  epilepsy. 


'^'■''"V^ 


\. 


Fig.  143. — Acute  dilatation  of  stomach  with  tachycardia. 

Epilepsy. — Mangelsdorf^  has  demonstrated  acute  ectasy  during 
the  convulsive  seizure  and  the  gradual  return  to  normal  position 
(Fig.  141). 

Migraine. — The  same  author  noted  similar  conditions  during 
attacks  of  migraine  (Fig.  142),  and  reports  ^oo  cases  in  epilepsy 
and  migraine. 

Lauder  Brunton-  noted  transitory  dilatation  in  sick  headache. 

Tetany. — Broadbent^  describes  a  case  of  acute  ectasy  with  tetany, 
which  ended  in  recovery. 

'  Atonia  Gastrica,  Rose  and  Kemp. 

2  Allbutt's  System  of  Medicine,  vol.  iii,  p.  392. 

^  Practitioner,  igo8. 


312 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


Chorea. — Acute  ectasy  has  been  reported  as  a  terminal  event  in 
chorea.^ 

3.  Acute  Ectasy  Producing  Acute  Cardiac  Symptoms. — Tachy- 
cardia.— Girl,  age  twenty-one,  with  chronic  endocarditis,  excellent 
compensation,  no  gastric  disturbances.  Tachycardia,  210  beats  per 
minute,  followed  dietary  indiscretion.  Acute  ectasy  was  found  as  in 
Fig.  143.  Emesis  occurred,  the  stomach  contracted  to  normal  size, 
and  the  tachycardia  ceased.  The  patient  suffered  from  several  attacks, 
but  has  had  no  further  trouble  since  she  has  exercised  care  in  diet. 

Pseudo-angina  Pectoris. — Female,  age  sixty-five,  suffered  from 
attacks  of  pseudo-angina,  following  dietary  indiscretions,  at  times 


Fig.    144. — Acute  dilatation  of  the  stomach  with  symptoms  of  pseudo-angina 

pectoris. 


consciousness  was  lost.  A  number  of  attacks  occurred  and  in  every 
instance  acute  ectasy  w^as  present,  as  in  Fig.  144.  Emesis  relieved 
both  the  dilatation  and  the  attack.  Ultimate  cure  resulted  from 
proper  diet. 

4.  Acxde  Ectasy  Complicating  Infectious  Diseases,  Notably  Typhoid 
and  Pneumonia. — The  tympanites  of  typhoid  is  frequently  not  purely 
intestinal.  Acute  gastro-intestinal  dilatation  is  by  no  means  rare; 
in  fact,  I  have  found  it  quite  frequent.  Systemic  infection  or  im- 
proper diet  cause  this  condition.  Acute  gastroduodenal  dilatation 
has  been  reported. 

In  the  milder  types  of  acute  gastro-intestinal  dilatation  there  is 
1  Lancet,  April  19,  1890. 


ACUTE    DILATATION    OF   THE)    STOMACH 


313 


often  no  romiting.  There  are  cardiorespiratory  symptoms  which 
might  suggest  pulmonary  involvement.  Examination  shows  acute 
distention.  Postural  treatment/  by  elevation  of  the  head  of  the 
bed,  enteroclysis,  and  lavage,  will  relieve  the  symptoms.  The  same 
mixed  type  of  distention  may  occur  wdth  pain  and  shock  and  simulate 
perforation.  After  relief  of  the  distention,  examination  shows 
absence  of  muscular  rigidity  (no  peritonitis) . 


.-T^^&ST^ 


Fig.  145. — Acute  dilatation  of  the  stomach,  with  constipation  (ten  days'  duration) 
a  prominent  symptom. 


In  the  acute  distention  of  typhoid,  with  intestinal  hemorrhage, 
lavage  will  relieve  gastric  distention  and  diminish  intra-abdominal 
tension.     I  have  never  seen  it  recommended. 

Pneumonia. — We  may  have  the  gastroduodenal  type  of  acute 
ectasy,  of  which  several  cases  are  reported.  The  mixed  type  is  quite 
common  and  constitutes  a  serious  danger.  Undoubtedly  sudden 
heart-failure  has  been  precipitated  by  this  condition.  The  etiology 
and  treatment  are  the  same  as  in  typhoid  fever.  There  is  greater 
1  See  Treatment  of  Typhoid  Fever. 


314 


DISEASES    OP   THE    STOMACH   AND    INTESTINES 


danger  to  the  heart  from  the  pressure  than  from  the  passage  of 
the  stomach -tube. 

5.  Acute  Ectasy  with  Coprostasis  the  Prominent  Symptom. — 
Male,  age  fifty-five,  following  indiscretions  in  diet,  complained  chiefly 
of  coprostasis,  with  occasional  vomiting.  Constipation  had  been 
present  eight  days  when  I  saw  the  case.  Fecal  impaction  was 
present  in  the  sigmoid  and  caput  coli. 

Frequent  lavage,  enteroclysis,  and  cathartics  relieved  the  con- 
dition.    In  Fig.  145  is  depicted  the  stomach  before  and  after  relief. 


Fig.  146. — Acute  dilatation  of  the  stomach  engrafted  on  chronic  dilatation. 

6.  Acute  Dilatation  Supervening  on  Chronic  Ectasy. — Female, 
age  forty-five,  suffered  from  chronic  ectasy  due  to  pyloric  stenosis 
from  ulcer.  Following  a  dietary  indiscretion,  acute  ectasy  resulted 
with  gastrosuccorrhea,  pain,  vomiting,  peristaltic  waves,  constipa- 
tion, and  coljapse. 

In  Fig.  146  is  shown  the  acute  ectasy,  with  return  to  the  position 
of  chronic  ectasy  after  lavage.  Subsequently  gastro-enterostomy 
was  performed  with  a  gain  of  100  pounds  in  the  patient's  weight. 

Symptoms  of  the  Severe  Cases. — The  symptoms  are  charac- 
teristic, and  are  as  follows: 


acute;  dilatation  of  the  stomach  315 

Sudden  abdominal  distention,  pain,  tenderness,  excessive  vomit- 
ing, constipation,  thirst,  scanty  urine,  and  collapse.  It  has  been 
mistaken  for  intestinal  obstruction  or  for  peritonitis. 

Onset. — This  is  nearly  always  sudden.  The  patient  may  be  well 
or  suffer  from  some  illness  taking  its  usual  course,  when  he  suddenly 
complains  of  great  distention,  discomfort,  or  severe  pain  in  the 
abdomen.  This  is  rapidly  followed  by  vomiting,  which  is  the  most 
constant  symptom,  begins  early,  and  generally  persists  throughout 
the  attack.  Rarely  there  may  be  an  intermission  due  to  tem- 
porary cessation  of  secretion,  or  cessation  of  vomiting  may  be  a 
terminal  event,  the  abdominal  muscles  and  diaphragm  being  no 
longer  able  to  expel  the  contents.  Cessation  of  vomiting  is,  therefore, 
not  always  a  favorable  symptom. 

The  vomiting  is  profuse,  in  large  amounts,  and  comes  up  in  gulps 
without  straining.  In  the  early  stage  it  may  consist  of  the  gastric 
contents,  of  food  in  various  degrees  of  fermentation ;  later,  it  becomes 
thinner  and  watery,  and  generally  of  a  greenish  hue.  It  is  often 
described  as  bilious.  It  may  be  brownish,  grayish,  or  even  inky 
black;  occasionally  there  may  be  a  trace  of  blood.  Often  in  the 
postoperative  cases  acute  distention,  pain,  and  greenish  vomiting 
are  the  first  symptoms.  The  vomitus  may  be  sour  or  foul  or  even 
(rarely)  feculent  in  odor. 

Character  of  the  Vomitus. — Various  constituents,  such  as  bile, 
diastase  ferment,  hydrochloric  acid,  lactic  acid  and  traces  of  blood, 
visible  or  occult,  have  been  found. 

Pain  is  present  in  the  majority  of  cases,  usually  in  the  epigastric 
and  umbilical  regions.  In  the  gastro-intestinal  mixed  cases  at  the 
commencement  it  is  more  general  and  acute  from  sudden  distention, 
being  suggestive  of  peritonitis^;  later  there  is  a  feeling  of  distention, 
not  so  acute,  with  accompanying  cardiorespiratory-  symptoms.  It 
differs  from  the  continuous  pain  of  acute  obstruction. 

Tenderness  occurs  in  some  cases.  Muscular  rigidity  is  absent. 
The  urine  becomes  scanty  and  nearly  suppressed  during  the  last 
twenty-four  hours.  Anuria  is  diagnostic  of  obstruction  high  up  in 
the  intestinal  tract,  and  does  not  occur  with  obstruction  of  the  large 
intestine.  It  has  been  mistaken  for  uremia.  The  temperature  is 
usually  normal  or  subnormal,  unless  the  patient  has  fever.  Thirst 
is  marked.  Hiccough  may  occur  as  a  terminal  symptom,  as  may 
also  delirium.  General  muscular  cramps  occurred  in  one  case;  and 
Broadbent  reports  a  case  of  tetany. 

Physical  Signs. — In  the  gastric  or  the  gastroduodenal  type  there 
is  distention  of  the  abdomen,  but  the  swelling  is  not  uniform;  it 
chiefly  fills  the  left  half  and  lower  part  of  the  abdomen,  and  the  right 
hypochondrium  appears  to  be  flattened.  There  is  often  swelling 
in  the  epigastrium. 

The  following  is  of  service:  Draw  a  line  from  the  tip  of  the 
'  Sudden  perforation  may  even  be  suspected. 


3i6 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


ensiform  to  the  junction  of  the  middle  and  outer  third  of  Poupart's 
Hgament  (Fig.  147).  The  distention  usually  Hes  to  the  left  and 
below  this  oblique  line.  Occasionally  it  appears  more  below  the 
navel  and  sometimes  there  is  general  distention. 

Splashing  sounds  (succussion)  and  the  sense  of  fluctuation  are  an 
aid  in  some  cases.  They  are  not  always  present  in  the  early  period, 
when  there  is  chiefly  gas  in  the  organ.  They  occur  below  the  level 
of  the  umbilicus. 

Percussion  will  show  the  resonance  increased,  but  will  be  interfered 
with  when  there  is  much  fluid.  It  is  important  when  the  splash 
is  absent. 

Peristaltic  waves  of  contraction  occur  very  seldom.  They  are 
found  only  before  complete  paresis  takes  place,  or  in  the  acute  cases 

engrafted  on  the  stenotic  type  of  chronic 
dilatation. 

The  general  symptoms  are  those  of 
collapse,  a  rapid  and  small  pulse,  fre- 
quent respiration,  a  clammy  skin,  and 
subnormal  temperature. 

Dttration  of  the  Attacks. — The  dura- 
tion of  the  attack  depends  on  its  severity 
and  type  of  case.  In  my  case  of  tachy- 
cardia it  lasted  less  than  an  hour.  In 
the  mixed  cases  it  depends  on  the  treat- 
ment accorded  by  the  physician. 

Among  the  severe  cases,  1  case  of 
Conner's  died  within  three  hours  after 
the  onset  of  the  pain,  which,  with  disten- 
tion, was  the  first  symptom.  There  was 
no  vomiting.  Several  cases  died  within 
twenty-four  hours,  and  sixteen  days  w^as  the  longest  duration.  The 
average  was  about  five  days.  Some  cases  recur  or  several  weeks  may 
elapse  before  the  dilatation  entirely  disappears. 

Prognosis. — In  the  severe  cases  it  has  been  extremely  bad, 
being  a  most  formidable  condition.  There  is  a  72  per  cent,  death-rate 
recorded.  In  realitv  many  cases  occur,  and  with  our  present  know- 
ledge the  mortality  should  be  comparatively  small. 

Morbid  Anatomy. — The  post-mortem  appearance  of  the  stomach 
is  quite  characteristic,  being  cylindric  and  bent  into  a  horseshoe  or 
V -shape.     The  cardiac  portion  is  the  longer  (Fig.  148). 

The  walls  of  the  stomach  are  distended  and  thinned.  A  large 
amount  of  elasticity  is  retained,  as  shown  by  the  shrinking  that 
takes  place  after  the  distending  force  is  removed.^  The  stomach 
may  occupy  the  entire  abdomen  or  even  reach  into  the  pelvis.  It 
has  been  mistaken  on  operation  for  cyst  of  the  pancreas.  Its  color 
may  be  purplish  red,  grayish,  or  bluish  white. 

1  McEvitt,  New  York  State  Journal  of  Medicine,  July,  1906. 


Fig.  147. — Line  drawn  from 
ensiform  to  Poupart's  liga- 
ment. 


ACUTE    DILATATION    OF    THE    STOMACH  317 

Microscopic  Examination. — This  has  been  made  in  a  few  cases. 
There  was  thinning  of  the  musculature  and  no  definite  microscopic 
changes  were  noted,  though  in  some  there  were  small  hemorrhages. 

Duodenum. — In  a  large  number  of  cases — over  50  per  cent. 
(Conner) — a  part  or  the  whole  of  the  duodenum  shared  in  the  dilata- 
tion; in  many  the  distention  stopping  where  the  mesentery  crossed. 
Kinks  have  also  been  found  in  the  duodenum.  The  coils  of  the 
intestines  are  flattened  and  collapsed  in  the  pelvis. 

Diagnosis. — One   should   always  think  of  the   possibility  that 
tachycardia,   convulsions,   epilepsy,   migraine,   anginoid   symptoms, 
increased  cardiac  and  respiratory  rapidity,  and  even  tetany  may  oc- 
cur with  acute  ectasy.     Sudden  gastro-intestinal  dilatation  is  quite 
frequent  in  typhoid  and  pneumonia.     Often  vomiting  is  absent  in  the 
milder  cases,  and   the  chief  symp- 
tom  pointing   to    the   abdomen    is  j, 
distention.     AX  times  there  may  be 
acute   pain   in   typhoid,  simulating 
perforation.     Examination  in  every           ^-  "'"" 
case  should  be  made  hy  percussion,       /, 
the  splashing  sound,  and  especially      ' 
hy  lavage,  if  there  is  any  douht. 

Intestinal  irrigation  (recurrent) 
will  often  relieve  distention  when 
present,  and  aid  in  diagnosis. 

Postnarcotic    vomiting    may    be-  :|,\  ,  " 

come  gradually  persistent,  and  this  mi- 

should  be  looked  on  with  suspicion.  Wf 

Pain,  tenderness,  distention,  con- 
tinuous vomiting  of  bilious  appear- 
ance are  suggestive,  especially  with 

collapse,    rapid    and    feeble    pulse,      Rg.  .^g.-Post-mortem  appearance 
urinary  suppression,  and  obstinate       of  acute  dilatation  of  the  stomach. 
constipation. 

In  the  severe  cases  there  may  be  occasionally  no  vomiting  and 
no  -pain,  but  only  acute  distention  and  some  diarrhea.  The  use  of 
the  stomach-tube  and  determining  the  position  of  the  stomach  before 
and  after  its  employment  are  of  value  in  all  cases. 

//,  after  lavage,  the  distention  disappears  and  there  is  no  distention 
of  the  intestines  or  only  slight  tympanites  in  the  colon,  the  acute 
dilatation  is  of  the  stomach  or  of  the  gastroduodenal  type. 

If  intestinal  distention  persists,  the  dilatation  is  of  the  mixed  type. 

If  all  the  tympanites  is  reheved  by  enteroclysis,  subsequent 
examination  will  determine  the  stomach  not  to  be  dilated. 

The  presence  of  pancreatic  juice,  absence  of  fecal  vomiting,  and 
presence  of  bile  show  the  gastroduodenal  type.  This  is  especially 
true  if  the  abdominal  posture  affords  relief.  Bile,  however,  may  be 
present  with  acute  gastric  distention  alone. 


3l8  DISEASES   OF    THE    STOMACH   AND   INTESTINES 

True  stercoral  vomiting  shows  obstruction  lower  down,  and 
muscular  rigidity  is  a  symptom  of  peritonitis. 

Treatment. — Prophylaxis. — Rapidity  in  operating,  the  minimum 
amount  of  manipulation  of  the  viscera,  a  minimum  quantity  of 
anesthesia,  and  care  in  feeding  after  operation  are  important. 

The  abolition  of  milk-diet  in  typhoid  fever,  pneumonia,  and 
acute  infectious  diseases  is  advisable,  with  the  substitution  of  broths, 
strained  soups  of  various  kinds,  as  barley,  rice,  and  gruels.  If  the. 
patient  has  had  an  attack,  then  the  conditions  of  the  gastric  secre- 
tion should  be  investigated,  irregularities  corrected,  and  proper  diet 
instituted. 

In  every  case  of  acute  ectasy  the  stomach  should  be  immediately 
evacuated  by  lavage.  It  is  an  error  to  wait  until  the  symptoms 
appear  marked,  or  until  the  patient  vomits,  before  lavage  is  insti- 
tuted.    The  stomach  may  redistend  in  the  severe  cases. 

It  is  advisable  to  repeat  lavage  within  two  hours  or  at  times  in 
three  hours,  and  thereafter  every  four  to  six  hours,  during  the  first 
twenty-four  hours,  depending  on  the  physical  signs  and  symptoms. 
It  may  be  necessary  to  perform  it  more  frequently.  At  times  it 
must  be  carried  out  for  some  days.  It  is  safer  to  err  on  the  side  of 
frequency. 

No  food  or  drink  should  he  given  by  mouth.  For  severe  thirst, 
saline  enemata,  proctoclysis,  or  even  hypodermoclysis  may  be 
administered.  They  are  also  efficient  in  the  collapse,  and  infusion 
may  be  required.  Rectal  feeding  must  be  kept  up  for  several 
days  until  symptoms  disappear. 

If  there  is  intestinal  distention,  continuous  rectal  irrigation  is  of 
value.  It  is  advisable  to  promote  peristalsis  as  soon  as  possible. 
Unless  hemorrhage,  peritonitis,  or  appendicitis  complicate  (as  might 
occur  in  typhoid),  or  there  be  a  suspicion  of  a  true  intestinal  obstruction, 
after  washing  the  stomach  with  plain  water,  in  which  milk  of  mag- 
nesia, 2  oz.  (60.0),  has  been  dissolved,  I  give  calomel,  gr.  3  to  5  (0.2- 
0.3),  in  water,  ^ss  (16.0),  directly  through  the  stomach-tube  before 
removal;  and  a  saline  cathartic  by  the  same  method  four  to  six" 
hours  later. 

In  some  cases  I  have  given  by  preference  a  high  enema^  of  oiv 
(125  cc.)  of  a  saturated  solution  of  magnesium  sulphate  two  hours 
after  lavage. 

Tincture  of  belladonna  is  useful.  It  lessens  the  secretion,  relaxes 
pyloric  spasm,  and  has  an  excellent  effect  on  the  atony.  It  should 
be  given  in  TTLv  to  x  (0.296-0.592)  doses  on  the  tongue,  with  strychnin, 
gr.  gV  to  aV  (0.00108-0.002 1 2),  every  four  to  six  hours  by  hypodermic 
injection.  The  latter  stimulates  the  musculature,  the  heart,  and 
respiration.  Atropin,  gr.  i/jo  (0.00065),  ^nay  be  substituted  h^^poder- 
mically  for  belladonna. 

Physostigmin  sulph.  (eserin),  gr.  tto  (0.00065),  has  been  recom- 
^  This  may  be  preferable,  lest  the  patient  vomit  the  saline  cathartic. 


ACUTE    DILATATION    OF    THE    STOMACH  319 

mended  to  promote  evacuation  of  the  bowel.  I  have  recently 
employed  gr.  5V  (0.0013)  every  two  hours  for  several  doses  with  suc- 
cess. It  is  well  to  arrange  to  give  strychnin,  gr.  jo 0  to  gV  (0.00065- 
0.00108),  to  guard  the  eserin. 

Rectal  electric  irrigations  of  the  bowels  are  efficacious  for  obsti- 
nate constipation. 

The  second  most  important  therapeutic  measure  is  postural 
treatment.  The  position  depends  on  the  anatomic  type  of  the  dilata- 
tion. 

(i)  The  semi-obHque  or  nearly  sitting  position,  the  head  of  the 
bed  is  blocked  up  as  in  the  illustration  under  Typhoid  Fever.  The 
patient  lies  on  an  inclined  plane.  This  is  of  value  in  the  acute 
gastro-intestinal  (or  mixed)  type,  with  general  abdominal  distention, 
so  frequent  in  typhoid  or  pneumonia,  where  the  cardiac  and  respi- 
ratory symptoms  are  pronounced  jrovi  abdominal  pressure.  By 
elevation  of  the  head  of  the  bed  in  one  severe  case  of  typhoid  the 
tympanitic  area  in  the  thorax  lowered  4  inches,  and  the  pulse  and 
respiration  dropped  20  points  each. 

A  fatal  issue  may  result  from  pressure-effects  on  the  heart  and 
lungs  with  this  type. 

Frequent  lavage  and  enteroclysis  should  be  instituted  in  these 
cases,  and  later  milk-free  diet,  substituting  soups  and  broths. 

This  method  would  be  incorrect  in  the  gastroduodenal  type  of 
dilatation. 

(2)  Elevation  of  the  foot  of  the  bed  to  relieve  pressure  on  the  - 
duodenum.     The  objectionable  feature  is  the  danger  from  pressure 
on  heart  and  lungs  if  the  stomach  should  begin  to  redilate. 

(3)  In  the  acute  gastroduodenal  type  the  lateral  position,  on  the 
right  or  left  side,  has  relieved  the  symptoms.     The  patient  recovered. 

(4)  The  abdominal  position  {patient  lying  on  the'belly)  is  the  best 
m,ethod  to  treat  the  acute  gastroduodenal  type. 

That  this  position  affords  relief  seems  to  me  to  show  quite  con- 
clusively that  this  type  of  obstruction  is  caused  chiefly  by  the  stomach 
pressure  on  the  transverse  duodenum. 

Baumler  kept  the  patient  fifteen  minutes  in  the  knee-elbow 
position  in  each  two  hours ;  the  balance  of  the  time  on  the  belly. 

Operations. — These  have  not  generally  proved  successful.  Among 
those  performed  or  suggested  were : 

The  stomach  opened  and  evacuated,  and  gastro-enterostomy. 
Gastric  fistula  might  be  tried.  A  kink  at  the  duodenojejunal  junc- 
tion was  relieved  in  one  case,  and  the  patient  recovered. 

Recovery  has  also  been  reported  after  one  case  of  gastro-enteros- 
tomy. 

Frequent  lavage,  combined  with  postural  treatment,  enteroclysis, 
and  securing  bowel  action  as  soon  as  possible  are  indicated. 


320  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

CHRONIC  DILATATION  OF  THE  STOMACH 

(Synonyms. — Ectasy;   Ectasia  Ventriculi;   Gastrectasy;   Ischochymia — E inborn; 
Motor  Insufficiency  of  the  Second  Degree — Boas.) 

The  term  "dilatation  of  the  stomach"  is  employed  for  descriptive 
purposes,  but  in  view  of  the  existence  of  an  acute  type  of  dilatation 
of  the  organ,  chronic  dilatation  of  the  stomach  would  seem  a  prefer- 
able nomenclature. 

Definition. — How  may  dilatation  of  the  stomach  be  defined? 
Is  it  to  be  measured  by  the  capacity  of  the  stomach  alone  or  by  the 
increased  capacity  plus  the  alteration  of  its  functions?  The  latter 
is  correct.  The  capacity  of  the  normal  stomach  is  extremely  variable. 
Ziemssen  has  shown  that  a  stomach  may  be  normal  and  only  contain 
8  ounces  (250  cc),  whereas  another  stomach,  also  normal,  may  pos- 
sess a  capacity  of  2  quarts  (Hters).  The  large  stomach  ("megalogas- 
tria"),  at  times  found  during  a  physical  examination,  produces  no 
symptoms.  This  may  be  congenital  or  acquired  by  large  eaters  or 
by  those  who  live  on  vegetable  diet.  Such  cases,  however,  can  read- 
ily develop  atony.  As  long,  however,  as  the  functions  of  the  stomach 
are  normal  we  cannot  regard  the  conditions  met  with  as  pathologic, 
and  hence  cannot  consider  that  dilatation  exists. 

As  already  described,  the  lower  border  of  the  normal  stomach 
when  distended  with  food  or  liquid  lies  from  ij  to  2  fingers-breadth 
above  the  level  of  the  umbihcus.^  If  it  descends  to  nearly  the  level 
of  the  umbilicus,  to  its  level  or  below  it,  and  symptoms  accompany 
it,  we  must  consider  the  organ  dilated. 

One  must  not  commit  the  error  of  mistaking  gastroptosis  for 
dilatation.  With  gastroptosis  the  upper  border  of  the  stomach 
descends  as  well  as  the  lower  border,  and  there  are  movable  kidney 
and  enteroptosis. 

The  prolapsed  stomach  may,  in  addition,  be  dilated.  There  are 
varying  degrees  of  gastroptosis.  With  dilatation  the  upper  border 
of  the  stomach  does  not  descend,  but  maintains  its  relation  to  the 
diaphragm,  and  the  stomach  is  dilated  chiefly  in  the  direction  to 
which  the  greatest  force  is  applied,  downward  and  laterally.  The 
muscular  fibers  first  elongate  in  the  vertical  direction  and  the  distance 
between  the  lesser  and  the  greater  curvature  is  increased.  Dilatation 
may  also  ensue  in  the  transverse  and  anteroposterior  dimensions  and 
the  pylorus  may  be  a  little  further  to  the  right  and  in  a  slightly  lower 
plane,  but  the  lesser  curvature  maintains  its  relation  to  the  dia- 
phragm, and  this  is  the  differential  point  between  dilatation  and 
gastroptosis  (Fig.  149). 

There  is  confusion  as  to  the  terms  "atony,"  "ectasy,"  and 
"motor  insufficiency,"  as  they  are  often  used  interchangeably  by 
different  authors. 

1  Examination  of  normal  subjects,  complaining  of  tio  symptoms,  will  fre- 
quently show  that  the  stomachs  are  abnormally  large,  or  in  an  abnormal  posi- 
tion.    Such  cannot  be  considered  pathologic. 


CHRONIC    DILATATION    OF   THE    STOMACH 


321 


Atony  oi  the  stomach  may  be  defined,  as  aheady  stated,  as  a  loss 
of  tone  or  contractile  power  of  the  muscles  of  the  stomach,  so  that 
the  organ  does  not  contract  about  its  contents,  with  a  resulting 
motor  insufficiency  {inability  to  expel  its  contents  within  the  normal 
limit  of  time).     This  condition  has  not  progressed  to  dilatation. 

Ectasy  may  be  defined  as  dilatation,  an  enlargement  of  the  stomach 
permanent  in  character,  combined  with  motor  insufficiency.  With 
the  atonic  type  of  ectasia,  there  is  motor  insufficiency. 

Relative  Motor  Insufficiency.— When  there  is  dilatation  of  th2 
stomach  due  to  obstruction  at  the  pylorus,  the  motor  power  of  the 
stomach  is  not  sufficient  to  expel  the  stomach  contents  within  nor- 
mal time  limits.  This  is  spoken  of 
as  insufficiency. 

This  should  be  considered  a  rela- 
tive insufficiency,  as  in  this  type 
the  musculature  of  the  stomach  is 
hypertrophied,  especially  at  the 
pyloric  end,  and  the  contractile 
power  is  often  increased,  but  not 
sufficiently  to  expel  the  contents 
past  the  obstruction  within  the 
normal  time. 

In  the  dilated  stomach  without 
pyloric  obstruction  we  have  the 
true  atony  of  the  musculature,  with 
varying  degrees  of  motor  insuf- 
ficiency. 

Some  claim  that  stenosis  exists 
in  all  cases  of  dilatation  of  the 
stomach,  but  it  is  easy  to  demon- 
strate that  there  are  two  distinct 
types  of  chronic  dilatation  of  the 
stomach  differing  in  symptoms  and 
pathologic  findings: 

.  (i)  The  atonic  type  of  chronic 
dilatation  of  the  stomach.     (2)  The  stenotic  (obstructive)   type  of 
chronic  dilatation  of  the  stomach. 

Differential  Diagnosis.— A ton/c  Type.— In  the  atonic  type  there 
may  be  few  or  no  symptoms  pointing  directly  to  the  stomach,  the 
patient  frequently  suffering  from  nervous  symptoms  due  to  auto- 
intoxication and  from  intestinal  disturbances.  I  have  seen  many  such 
cases  at  the  Manhattan  State  Hospital  continue  a  year,  or  even  four  or 
five  years,  without  vomiting.  There  are  no  peristaltic  waves  and 
cramp-like  pains  such  as  occur  in  the  stenotic  type  followed  by  vom- 
iting; though  some  may  have  dyspeptic  symptoms  and  rarely  an 
attack  of  vomiting.  The  post  mortem  shows  the  stomach  often  enor- 
mously dilated,  with  thin  walls  and  no  evidence  of  pyloric  stenosis. 
21 


Fig.  149. — Dilatation  of  the  stomach. 


322  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Stenotic  Type. — In  the  stenotic  (obstructive)  type  of  dilatation 
dyspeptic  symptoms  are  marked,  there  are  peristaltic  waves  and 
cramp-like  pains  preceding  vomiting  of  large  quantities  of  gastric 
contents,  thirst,  etc. 

In  the  benign  type  of  long  duration  the  patient  often  suffers 
markedly  in  nutrition,  but  the  cachexia  and  other  symptoms  of 
malignancy  are  absent  and  the  disease  runs  a  long  course.  The 
post  mortem  shows  considerable  hypertrophy  of  the  musculature 
at  the  pyloric  end  of  the  stomach,  and  elsewhere  thinning  and 
dilatation  of  the  muscular  wall  with  the  evidence  of  stenosis  at  the 
pylorus,  or  constriction  from  some  external  factor. 

Atonic  Dilatation  of  the  Stomach 
Etiology. — As  causes,  we  may  have  a  primary  reduction  or  loss 
of  muscle  power  or  impairment  of  it  from  overwork,  for  example, 
from  the  ingestion  of  too  much  material.  It  directly  follows  chronic 
atony  of  the  stomach,  which  is  the  preliminary  stage,  and  hence 
there  are  similar  etiologic  factors,  such  as  wasting  disease,  tubercu- 
losis, chronic  gastritis,  heart  disease,  etc. 

Among  other  causes  are  bolting  the  food,  frequent  overloading 
the  stomach,  excessive  drinking  of  large  quantities  of  fluid,  especially 
of  those  containing  much  gas ;  it  may  rarely  be  congenital ;  it  is  quite 
frequently  associated  with  rickets,  in  which  case  gastroptosis  is 
quite  often  also  present.  It  sometimes  follows  repeated  attacks 
of  acute  atony  or  acute  dilatation. 

Nothnagel  traces  back  some  cases  of  chronic  dilatation  to  improper 
methods  of  feeding  during  early  life.  Atonic  ectasy  we  frequently 
find  among  the  insane.  I  have  found  an  enormous  number  of  patients 
at  the  Manhattan  State  Hospital  suffering  from  this  condition,  and 
quite  a  number  of  the  women  with  gastroptosis,  and  frequently 
dilatation  associated  with  it.  Examinations  of  many  hundreds  of 
cases  during  the  last  five  years  show  that  very  few  stomachs  were 
in  the  normal  position  or  possessed  normal  functions.  Many  of  these 
cases  have  never  vomited  and  in  very  many  no  special  symptoms 
directed  attention  to  the  stomach.  Unquestionably  the  hahit  of 
bolting  the  food  common  to  such  patients  is  a  frequent  cause  of 
ectasy.  Among  the  acute  melancholies  in  whom  some  ultimate  cures 
resulted,  auto-intoxication,  in  some  cases  the  result  of  ectasy  ivith  fer- 
mentation or  putrefaction,  was  the  primary  factor  in  the  production 
of  the  nervous  symptoms.  In  the  epileptic  ward  one  case  suffering 
from  dilatation  (atonic)  with  gastroptosis,  and  absence  of  free  hydro- 
chloric acid,  had  suffered  from  numerous  epileptic  convulsions  both 
day  and  night,  averaging  140  seizures  per  month.  Under  simple  diet, 
initial  lavage,  and  at  present  diet  and  medication  directed  to  the 
gastro-intestinal  tract  alone,  she  has  had  no  convulsions  for  two  years 
and  a  half,  with  the  exception  of  one  week,  some  fourteen  months  ago, 
during  which  period  she  was  taken  off  diet  and  medication  while  in 


CHRONIC    DILATATION    OF"   THE    STOMACH  323 

the  general  hospital  ward  with  an  acute  nephritis.  Bromids  were 
only  given  two  months  at  the  commencement  in  small  dosage  to 
break  the  convulsive  habit.  I  have  also  another  case  of  epilepsy  with 
atonic  ectasia  and  hypochlorhydria,  who  has  gone  over  a  year  with- 
out a  seizure  under  gastro-intestinal  treatment  alone. 

Even  in  the  incurable  insane  this  atonic  type  of  dilatation  has  a 
direct  bearing  on  some  of  the  symptoms.  In  a  series  of  13  paretics, 
examined  for  the  late  Dr.  Dent  at  the  Manhattan  State  Hospital/ 
I  found  II  cases  of  atonic  dilatation  of  the  stomach  and  2  cases  of 
gastroptosis,  and  in  all  secretory  derangements  of  the  functions  of 
the  stomach ;  1 1  of  these  cases  had  at  some  time  of  the  day  a  tem- 
perature of  99.5  °  F.  and  upward,  in  one  102.5  °  F.  Under  treatment 
directed  to  the  gastro-intestinal  tract  the  temperature  was  lowered 
in  all  II  (in  some  to  normal),  the  convulsions,  which  were  present 
in  5  cases,  were  diminished  in  frequency,  and  in  one  patient  suffering 
from  attacks  of  syncope,  cessation  of  attacks  followed  treatment. 

The  atonic  type  of  ectasy  is  quite  common  in  many  nervous  cases 
and  is  undoubtedly,  in  some,  the  causeof  the  auto-intoxication,  and  the 
nervous  condition  is  secondary.  Atonic  ectasy  may,  therefore,  be  in 
many  cases  the  cause  of  various  nervous  conditions.  On  the  other 
hand,  ectasia  resulting  from  insufiicient  mastication  and  bolting  of 
food  among  many  of  the  nervous  and  insane  may  be  a  factor  in  the 
production  of  a  vicious  circle.  Beer  drinkers  and  diabetics  suffer  from 
this  type  of  dilatation.  Professional  men,  bankers,  and  brokers, 
from  their  irregular  habits  and  rapid  eating,  are  quite  liable  to  this 
form.  The  musculature  of  the  pylorus,  as  we  know,  is  much  thicker 
than  other  parts  of  the  stomach  wall,  and  the  latter  naturally  gives 
way  and  distends  more  readily.  This  does  not  constitute,  however, 
a  stenosis  at  the  pylorus.  Ultimately,  however,  the  pylorus  itself 
relaxes  in  these  atonic  cases,  which  undoubtedly  accounts  for  the 
usual  absence  of  vomiting  in  these  patients. 

This  type  of  ectasy  is  extremely  common. 

Symptoms  are  at  times  not  referred  to  the  stomach  at  all,  and 
often  point  to  the  nervous  system,  or  cause  an  exacerbation  of  a 
preexisting  nervous  condition.  The  patient  is  often  neurasthenic  or 
melanchoHc  with  the  symptoms  associated  with  these  conditions.  I 
have  seen  the  lower  border  of  the  stomach  in  atonic  ectasy  reach  nearly 
to  the  symphysis.  The  following  symptoms  are  generally  associated : 
Constipation  usually  marked,  rarely  diarrhea,  coated  tongue,  fre- 
quently headache,  and  at  times  dyspeptic  disturbances,  such  as  belch- 
ing and  pressure  after  eating,  though  often  these  symptoms  are  absent. 
In  a  few  cases  of  extreme  dilatation  there  may  be  occasional 
vomiting  of  large  quantities  of  fluid.  There  are  no  spasmodic  pains, 
no  peristaltic  waves,  and  no  marked  vomiting,  as  in  the  stenotic 
type.     In  atonic  ectasia  with  chronic  gastritis,  the  gastric  symptoms 

1  Proceedings  of  the  American  Psychological  Association,  Sixty-first  Annual 
Meeting,  April,  1905;  also  The  Medical  News,  July  8,  1905. 


324  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

of  the  latter  may  be  present,  in  addition  to  the  other  symptoms 
already  noted.  More  rarely  there  may  be  hyperchlorhydria^  with 
atonic  ectasy.  These  cases  suffer  from  the  symptoms  of  hyperchlor- 
hydria,  motor  insufficiency  is  present,  there  may  be  spasmodic  pains 
and  vomiting  of  considerable  severity,  the  vomitus  being  very  acid. 
These  cases,  as  already  noted,  have  been  mistaken  for  gastrosuc- 
corrhea.  After  lavage,  and  later  by  aspiration  of  the  contents  of  the 
empty  stomach,  one  readily  demonstrates  that  hypersecretion  is  not 
present.  The  symptoms  in  this  type  are  due  to  the  extreme  hyper- 
chlorhydria  and  to  spasm  of  the  pylorus  resulting.  Excellent 
results  are  secured  by  lavage  and  by  the  treatment  of  the  hyper- 
chlorhydria.  Most  of  the  so-called  cures  of  stenotic  ectasia  belong, 
I  believe,  to  this  class.  The  mild  types  belong  to  the  atonic  class, 
though  they  might  be  considered  border-line  cases.  In  the  milder 
cases  in  which  cure  results  without  operation,  organic  changes  at  the 
pylorus,  I  believe,  must  necessarily  have  been  slight,  while  the  severe 
cases  with  peristaltic  unrest  and  progressive  symptoms  should  be 
classed  under  stenosis.^ 

Gastric  Contents.— The  gastric  findings  are  variable;  fermenta- 
tion is  quite  frequently  present  and  hypochlorhydria  or  nearly  com- 
plete absence  of  free  HCl;  chronic  gastritis,  occasionally  hyperacidity ; 
mould  has  been  found,  and  in  cases  with  gastroptosis  and  dilatation 
at  Ward's  Island,  I  have  even  noted  achylia. 

The  usual  manifestations  are  toxemic  in  character,  with  intestinal 
fermentation  or  putrefaction  and  indicanuria. 

Course. — The  milder  cases  of  atonic  dilatation  are  quite  amenable 
to  treatment  and  can  be  cured.  The  severe  cases  do  not  run  so 
favorable  a  course,  and  I  have  seen  such  among  the  nerv^ous  and 
insane  where  the  dilatation  extended  nearly  to  the  symphysis.  I 
believe  that  in  this  type  drainage  by  gastro-enterostomy  is  indicated, 
since  lavage  and  diet  are  only  palliative. 

In  the  cases  of  ectasia  due  to  benign  stenosis  there  is  at  times, 
under  treatment,  a  temporary  improvement.  The  stomach,  from  an 
increased  hypertrophy  of  the  muscles  and  a  subsidence  of  the  hyper- 
emia at  the  pvlorus,  may  secure  a  certain  amount  of  compensation 
and  empty  its  contents  fairly  well  for  a  time,  but  usually  the  symp- 
toms return  and,  finally,  resection  of  the  pylorus  or  gastro-enterostomy 
become  imperative  in  order  to  save  the  life  of  the  patient.  I  have 
known  these  cases  to  drag  along  twelve  to  fifteen  years  without 
operation.  Thev  become  chronic  invalids.  Only  by  operative 
procedure  can  a  practical  cure  of  the  case  be  accomplished. 

If  the  stenosis  is  malignant,  then  the  course  depends  on  the 
extent  of  the  disease.  Even  in  those  cases  where  removal  cannot 
be  undertaken,  gastro-enterostomy  will  relieve  the  symptoms. 

^  I  have  found  a  number  of  such  cases  among  the  epileptics,  there  being  no 
vomiting  or  rarely  so,  and  no  peristaltic  unrest. 

2  These  last  cases,  which  do  not  rapidly  respond  to  treatment  of  the  hyper- 
chlorhydria,  should  be  referred  to  the  surgeon. 


CHRONIC    DILATATION    OF    THE)    STOMACH  325 


Obstructive  Type  (Stenotic)  of  Ectasia 

The  stenosis  causing  this  type  of  dilatation  of  the  stomach  may 
be  in  the  gastric  tissue  at  the  pylorus  or  near  the  pylorus  in  the 
duodenum,  or  it  may  be  external  to  the  stomach — intrinsic  and 
extrinsic  causes.  The  factor  causing  constriction  may  be  benign  or 
malignant  in  character,  which  would  modify  the  clinical  symptoms. 

Etiology. — (i)   Congenital  stenosis  of  the  pylorus. 

(2)  Acquired  stenosis,  such  as  from  ulcer,  cicatrices  following 
burns  from  acids  or  alkalis;  from  severe  gastritis,  causing  hyper- 
trophy at  the  pylorus ;  repeated  spasmodic  closure  of  the  pylorus  due 
to  hyperacidity  (spastic  stenosis  due  to  inflammation  or  irritation) ; 
benign  tumors;  pedunculated  polypi;  adhesions  at  the  pylorus; 
external  tumors ;  pressure  from  large  gall-stones  (in  the  gall-bladder) ; 
perigastric  adhesions;  spider-web  adhesions  (Morris)  from  the 
gall-bladder;  stenotic  hypertrophic  gastritis  (Boas),  a  fibrous  disease 
of  the  pylorus  (hnitis  plastica);  sclerosis  in  the  pyloric  end  of 
stomach  (Ottinger) ;  pressure  from  external  tumor ;  malignant  dis- 
ease of  the  pylorus. 

(3)  Stenosis  of  the  duodenum  from  ulcers,  cicatrices,  carcinoma, 
external  compressions,  adhesions,  kinks,  or  diverticula. 

It  is  the  modern  consensus  of  opinion  that  bile  may  regurgitate 
into  the  stomach  even  if  the  stenosis  is  present  at  the  pylorus,  as 
the  cicatricial  tissue  holds  it  open  in  many  cases ;  so  its  presence  or 
absence  does  not  always  aid  us  as  to  locating  whether  the  stenosis' 
be  pyloric  or  duodenal.  Continuous  regurgitation  of  bile  and  pan- 
creatic juice,  however,  is  suggestive  of  obstruction  of  the  duodenum 
below  the  common  duct. 

Movable  kidney  I  do  not  believe  has  any  relation  to  ectasy, 
but  when  associated  with  so-called  dilatation,  it  can  be  demonstrated 
that  the  latter  is  really  a  gastroptosis. 

Pathology.— In  the  stenotic  type,  the  musculature  at  the  pyloric 
end  of  the  stomach  is  much  thickened ;  the  fundus  is  much  thinner 
than  normal.  The  pathologic  findings  at  the  pylorus  vary  according 
to  ^ the  cause  of  the  stenosis.  The  intestines  are  pushed  downward 
and  the  liver  slightly  upward  when  marked  ectasy  is  present. 

Symptoms.— The  symptoms  of  dilatation  of  the  stomach  due  to 
pyloric  stenosis  are  quite  characteristic,  but  are  modified  if  the 
condition  is  cancerous,  or  in  the  special  type   described  by  R.  T. 

Morris. 

The  usual  symptoms  are  thirst,  dryness  of  the  throat,  dry  skm, 
oppression,  feeling  of  cramp-like  pains  of  considerable  severity, 
generally  associated  with  peristaltic  restlessness  of  the  stomach, 
eructation  of  odorous  gas,  vomiting  of  considerable  chyme,  often 
containing  remnants  of  food  taken  the  day  before.  This  may  occur 
from  once  to  several  times  a  day.  The  bowels  are  extremely 
constipated.     Emaciation    may   become  very  marked  and  the  loss 


326  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

of  adipose  on  the  abdomen  so  great  that  the  skin  is  in  dry  wrinkled 
folds.  The  urine  becomes  markedly  diminished  in  advanced  cases ; 
its  reaction  is  frequently  alkaline. 

Intestinal  fermentation  and  putrefaction  with  indicanuria  are 
often  present. 

Bradycardia  and  dyspnea  (cardiac  asthma)  at  tim.es  are  present, 
as  are  also  stupor,  headache,  and  so-called  gastric  vertigo. 

Tetany,  or  epileptiform  attacks  may  complicate  the  condition. 

The  benign  type  of  stenotic  dilatation  is  characterized  by  rather 
a  long  course,  with  often  considerable  temporary  improvement 
under  treatment,  with  a  tendency  to  relapse. 

In  the  malignant  type  we  have  the  marked  cachexia  and  rapid 
loss  of  weight  within  a  few  months,  the  age  of  patient  usually  over 
forty  or  forty-five,  and  the  character  of  the  vomitus  to  be  noted  later. 

In  my  experience  the  cases  characterized  by  attacks  of  gastro- 
succorrhpa  are  more  frequently  associated  with  ulcer  at  the  pylorus 
with  benign  stenosis. 

Special  Type. — In  an  interesting  type,  to  which  Robert  T.  Morris 
has  called  attention,  there  may  be  vomiting  of  considerable  blood, 
pain,  etc.,  suggestive  of  an  active  ulcer.  Gall-bladder  spider  adhesions 
have  been  found  to  be  the  factor.  The  symptoms  are  probably 
explainable  by  circulatory  interference.  The  history  of  previous 
gall-bladder  disease  should  be  looked  into. 

Examination  of  the  Gastric  Contents  in  Malignant  Pyloric 
Stenosis. — Coffee-ground  vomit,  or  the  presence  of  occult  blood; 
free  HCl  markedly  diminished  or  absent,  lactic  acid  present; 
few  or  no  sarcin(E  and  the  Boas-Oppler  bacilli  present,  in  connec- 
tion with  the  clinical  S3^mptoms,  are  diagnostic  of  malignant  stenosis. 
Meat  is  undigested.  Free  HCl  may  be  present,  especially  in  the  early 
stages,  or  when  the  carcinoma  is  engrafted  on  an  ulcer. 

With  benign  stenosis  we  have:  the  gastric  contents  separating 
into  three  layers,  the  upper  being  gaseous;  HCl  is  marked  (hyper- 
acidity) ;  yeast  and  sarcinae  are  abundant ;  undigested  starch  is  present. 
Mould  may  be  found  and  occasionally  bile  or  sulphuretted  hydrogen. 

I  agree  with  Einhorn  that  bile  can  enter  the  stomach  in  some 
cases  of  stenosis  of  the  pylorus,  the  thickened  tissue  allowing  a  sUght 
patency. 

Diagnosis 

Ectasy  means  dilatation  of  the  stomach  combined  with  motor 
insufficiency. 

We  must,  therefore,  first  determine  the  position  of  the  organ. 
Frequent  errors  have  been  made,  in  differentiating  dilatation  and 
gastroptosis.  The  position  of  the  upper  border  of  the  stomach  is 
the  chief  point. 

There  is  a  simpler  method  which  is  dependent  on  whether  or  not 
a  movable  kidney  be  present.     The  movable  kidney  is  almost  invari- 


CHRONIC    DILATATION    OF    THE    STOMACH  327 

ably  part  of  a  general  ptosis  of  the  viscera  (splanchnoptosis),  and 
movable  kidney  from  traumatism  is  extremely  rare. 

If  we  find  a  movable  kidney  with  a  stomach  whose  lower  border 
is  in  an  abnormal  position  (too  low  down) ,  the  diagnosis  is  gastropto- 
sis.  If  no  movable  kidney  is  present  and  the  greater  curvature  is 
low  down,  plus  motor  insufficiency  and  symptoms,  the  condition  is 
one  of  dilatation. 

An  extremely  simple  method  of  locating  the  lower  border  of  the 
stomach  is  by  the  splashing  sound  (succussion).  This  has  been  fully 
described,  and  also  the  creation  of  the  splash  for  diagnosis.  Dehio's 
method  can  be  used  as  a  check. 

We  may  employ  in  addition : 

(i)  Inspection,  which  will  in  some  cases  show  the  outline  of  the 
distended  stomach,  especially  after  distention  with  carbonic  acid 
gas.  Active  peristalsis  is  also  evident  on  inspection  and  is  diagnostic 
of  pyloric  obstruction. 

(2)  Palpation. — By  this  means  the  peristaltic  movements  may 
at  times  be  felt,  as  can  also  the  cushion-like  resistance  of  the  dis- 
tended stomach.  Occasionally  a  small  oval  tumor  can  be  determined 
in  benign  stenosis,  though  generally  it  is  not  appreciable.  In  carci- 
noma of  the  pylorus  the  hard  resistant  mass  can  often  be  appreciated. 

(3)  Percussion  and  auscultatory  percussion,  especially  before  and 
after  the  addition  of  water,  as  already  described,  are  useful.  The 
"scratch  method"  is  of  service. 

(4)  Inflation. — The  stomach  may  be  inflated  with  air  or  carbonic 
acid  gas.  The  outlines  can  thus  be  more  readily  determined  and  the 
position  of  the  upper  curvature  mapped  out.  Inflation  with  air  or 
water  renders  a  tumor,  if  present,  more  evident  to  percussion  and 
palpation  if  it  lie  on  the  anterior  wall.     It  disappears  if  posterior. 

(5)  Transillumination. — This  method,  especially  with  the  cir- 
cumscribing gastrodiaphane  and  fluorescein,  readily  determines  the 
outline  of  the  stomach  and  differentiates  between  dilatation  and 
gastroptosis  in  disputed  cases.^  The  use  of  mensuration  by  means  of 
stiff  sounds  is  deprecated. 

"  The  determination  of  the  motor  functions  is  most  important, 
as  motor  insufficiency  is  a  salient  feature.  There  are  different  degrees 
of  this  motor  insufficiency,  and  this  is  best  determined  by  the  test 
breakfast  or  test  meal. 

Test  Breakfast. — Ewald's  test  breakfast.  Aspirate  the  contents 
one  hour  later. 

(i)  Normal  position  of  the  stomach,  with  a  residuum  aspirated 
of  100  cc.  or  over,  and  symptoms,  show  atony  of  the  stomach. 

(2)  Descent  of  the  lower  border  of  the  stomach;  100  to  150  to 
200  cc.  residuum  or  more  with  symptoms  and  with  kidneys  in  normal 
position  show  dilatation  of  the  stomach. 

1  The  ar-rays  give  no  additional  information  over  the  methods  described,  and 
the  expense  is  an  objection. 


328 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


(3)  If  movable  kidney,  gastroptosis  is  present. 

Six  or  seven  hours  after  Leube's  test  meal  the  healthy  stomach 
should  be  found  empty.  If  undigested  food  is  found  (200  to  600  cc. 
or  more),  insufficiency  is  present  and  the  degree  of  insufficiency  is 
indicated  by  the  amount  of  residuum. 

It  is  always  preferable  to  wash  the  stomach  before  the  test  meal, 
so  as  to  get  rid  of  the  old  residuum  and  make  an  accurate  test.  If 
considerable  residuum  be  found  at  the  end  of  seven  hours,  a  further 
test  should  be  made.  Wash  the  stomach  and  directly  thereafter  give 
at  10  p.  M.  a  light  supper — a  little  soup,  a  slice  of  bread,  a  slice  of 
beef,  and  a  little  chopped  spinach;  a  small  amount  of  boiled  rice  or 
a  dozen  raisins  may  be  substituted  for  the  spinach.  Aspirate  and 
wash  the  stomach  twelve  hours  later  before  breakfast.  In  some 
cases  there  will  be  a  marked  residuum  after  seven  hours,  but  none 
after  twelve  hours;  in  others  there  will  also  be  considerable  after 
twelve  hours,  showing  different  degrees  of  insufficiency. 

The  stomach  should  be  washed,  as  well  as  aspirated,  to  remove 
all  the  contents. 

The  salol  and  olive  oil  tests  are  not  as  reliable. 


TABLE    OF    DIFFERENTIAL   DIAGNOSIS 


Atonic  Dilatation. 


Duration. 

Course. 

Tumor. 

Pain. 

Peristaltic 

lessness. 

Vomiting. 

Cachexia. 

Symptoms. 


Blood. 


Long  unless 

recently  ac- 
quired. 

Long,  often. 


None. 


Absent, 
rest-     None. 


Most  frequently 
absent. 

None,  but  some 
loss  of  weight. 

Often  toxemic, 
referred  to  ner- 
vous system 
and  not  spe- 
cially referred 
to  stomach ;  at 
times  gastric. 

None  in  vomi- 
tus. 


Gastrosuccorrhea.  Rare. 


Stenotic  Dilatation. 


Benign  stenosis 
of  pylorus. 

Quite  long,  two 
years,  generally 
considerably  more. 

Generally  intervals 
of  quiescence  or 
improvement. 

Occasional  (sinall 
and  smooth). 

Spasmodic  attacks. 

Marked. 
Frequent. 


Malignant  stenosis 
of  pylorus. 

Short,  few  months  to 
one  year  or  one 
year  and  a  half. 

Progressive. 


Present;  later  palp- 
able. 

Always  present  and 
exacerbations. 

Present  and  at  times 
marked. 

Fairly  frequent. 


None,      but      great     Present. 

emaciation. 
Marked  gastric.  Marked. 


None  except  in  gall- 
bladder adhesion 
cases. 

More  frequent  with 
ulcer. 


Coffee-grounds  in 
Vomit  or  occult 
blood. 1 

Generally  absent, 
though  occasional. 


1  Blood  or  occult  blood  present  in  stool  in  cancer. 


CHRONIC    DILATATION    OF    THE    STOMACH 


329 


Gastric  Contents 


Atonic 

Dilatation. 

Benign  Stenosis. 

Malignant  Stenosis. 

Total  acidity. 

Lessened;   more 

Increased. 

Generally         dimin- 

rarely in- 

ished. 

creased. 

Free  hydro- 

Often         hypo- 

Generally  increased. 

Usually  absent. 

chloric  acid. 

chlorhydria; 
more  rarely  hy- 
perchlorhydria. 

Lactic  acid. 

At    times    pres- 

Absent. 

Present,  marked  usu- 

ent. 

ally. 

Fermentation. 

Often  marked. 

At  times  marked. 

At  times,  depending 
on  location  of 
growth. 

Odor. 

Often  present. 

Unpleasant. 

Fetid  at  times. 

Boas-Oppler  ba- 

-    Occasional. 

Rare. 

Usually  present. 

cilli. 

Mucus. 

At  times,  if  gas- 
tritis. 

At  times,  if  gastritis. 

In  some  cases. 

Sarcinae. 

Present  often. 

Present  markedly. 

Usually  absent. 

Yeast. 

Marked  often. 

Often  present. 

Pronounced  yeast 
fermentation  rare. 

Treatment 

The  treatment  of  chronic  dilatation  of  the  stomach  varies  con- 
siderably, depending  on  whether  it  be  due  to  atony  or  to  benign  or 
malignant  stenosis. 

Atonic  Dilatation, — This  is  by  far  the  most  frequent  type  of 
dilatation  which  we  are  called  upon  to  treat,  especially  among 
bankers,  brokers,  and  professional  men,  who  habitually  overeat, 
bolt  their  food,  or  are  heavy  drinkers.  Associated  with  or  having 
a  direct  bearing  on  this  condition,  we  may  find  hypochlorhydria, 
hyperchlorhydria,  or,  at  times,  chronic  gastritis.  Some  of  these 
cases  are,  in  their  incipiency,  of  rather  mild  type,  and  prophylaxis, 
as  regards  avoiding  rapidity  of  eating  and  eliminating  indigestible 
food  and  overeating,  is  of  value.  If  the  patient  is  run  down  or 
anemic,  iron  and  tonic  treatment  are  indicated. 

Diet. — Though  some  have  recommended  a  so-called  dry  diet 
in  dilatation  of  the  stomach,  it  is  a  well-known  fact  that  liquids  are 
first  evacuated  from  the  stomach,  then  mushy  food,  and  finally  solid 
food,  and  this  scientific  knowledge  should  be  our  guide  in  feeding 
such  cases.  Water  and  food  soluble  in  water  leave  the  stomach 
soonest  of  all. 

Large  quantities  of  fluid  should  not  be  given  at  a  time  lest  they 
overdistend  the  flaccid  stomach,  but  if  they  are  administered  in 
smaller  quantities  at  frequent  intervals,  a  considerable  amount 
can  be  employed. 

It  has  been  demonstrated  that  alcohol,  sugar,  and  dextrin  cause 
a  secretion  of  water  into  the  stomach. 

Milk  has  been  usually  recommended  as  the  standard  diet  in  this 
condition  as  possessing  highly  nutritive  properties,  and  the  statement 
has  been  made  that  it  does  not  stay  in  the  stomach  much  longer  than 
plain  water. 


330  DISEASES   Olf  THE  STOMACH  AND  INTESTINES 

Penzoldt  has  demonstrated  that  water,  cocoa,  meat  broth,  soft- 
boiled  eggs,  and  boiled  milk  (loo  to  200  gm.)  leave  the  healthy  stom- 
ach within  one  to  two  hours,  cooking  altering  the  curd  formation. 

Raw  milk  takes  a  considerably  longer  period,  and  curds  have 
been  found  frequently  in  the  normal  stomach  two  or  three  hours 
after  ingestion. 

Experiments  have  been  conducted  on  my  service  at  the  Manhattan 
State  Hospital  in  cases  of  dilatation  of  the  stomach,  and  the  periods 
for  the  raw  milk  to  remain  in  the  stomach  were  investigated.  After 
three  hours  large  masses  of  curd  were  aspirated. 

If  the  milk  were  diluted  one-half  with  water,  the  residuum  found 
at  a  certain  period  was  just  one-half  as  much  as  when  pure  raw  milk 
was  used,  which  formed  curds.  The  higher  the  dilution,  the  greater 
the  quantity  passed  from  the  dilated  stomach  within  a  definite  time. 
Another  objection  is  that  i  liter  of  milk  only  represents  about  640 
calories,  and  too  large  an  amount  would  be  required  if  sufficient 
nutrition  is  to  be  obtained  from  milk  alone.  Strained  soups  and 
strained  gruels  are  evacuated  more  rapidly.  If  milk  be  given,  it 
should,  preferably,  be  combined  with  some  strained  gruel  or  the 
latter  made  with  milk,  so  that  the  nutritive  value  may  be  increased. 

In  the  severer  type  of  cases  the  diet  suggested  by  Seibert  in 
typhoid  appeals  strongly  to  the  author.  It  possesses  considerable 
nutritive  value,  namely : 

Strained  rice,  oviij  (250  cc),  barley  or  oatmeal  soup  containing 
the  extract  of  J  pound  of  meat  and  the  yolk  of  a  fresh  egg.  This 
can  be  spiced  slightly  to  improve  the  flavor.  It  can  be  given  five 
or  six  times  daily. 

Strained  pea  soup,  lentil,  tomato,  or  potato  soup  can  be  used 
in  addition. 

Rice  flour  is  excellent  in  the  form  of  a  thin  gruel,  and  can  be 
made  with  milk  which  has  been  thoroughly  boiled.  The  object 
should  be  to  give  frequent  (five  or  six  smaller)  meals,  so  as  not  to 
overburden  the  stomach,  and  yet  secure  a  sufficient  amount  of 
nutrition  to  improve  the  patient's  physical  condition. 

Cream,  oij  (60.0)  in  oiv  (125  cc.)  of  water,  possesses  considerable 
nutritive  value. 

Crackers  heated  thoroughly  and  well  buttered  can  be  rubbed 
up  in  the  broth. 

Fat  in  the  form  of  cream  and  butter  should  be  administered. 

In  the  milder  cases,  scraped  beef,  rare  beef,  soft-boiled  eggs 
thickened  with  a  small  amount  of  mashed  potatoes,  and  rice  strained 
through  a  colander,  with  plenty  of  butter,  can  be  given,  with  a  little 
asparagus  and  spinach.  Other  vegetables  are  more  difficult  to  expel 
from  the  stomach. 

Matzoon,  kumyss,  bacillac,  kefir,  and  milk  prepared  with  lactone 
tablets  (lactone-buttermilk)  are  of  special  value  in  cases  suffering 
from  auto-intoxication  having  nervous  symptoms  and  indicanuria 


CHRONIC    DILATATION    OF   THE    STOMACH  33 1 

(intestinal  putrefaction).  The  matzooncan  be  diluted  with  one-third 
water  or  Vichy  that  has  been  allowed  to  become  flat.  This  last 
avoids  gaseous  distention  of  the  atonic  stomach.  It  is  also  prefer- 
able to  allow  some  of  the  gas  to  pass  off  from  the  kumyss.  About 
I  quart  of  one  of  these  preparations  can  be  used  daily — additional 
water  or  Vichy  one-third  in  volume  being  then  added.  These  sour 
milk  preparations,  especially  with  the  slight  dilution,  pass  readily 
from  the  stomach.  They  do  not  curdle  like  plain  milk.  The  yolks 
of  several  raw  eggs,  stale  bread  or  crackers  with  plenty  of  butter 
and  cream,  strained  vegetable  soups,  rice  gruel,  and  sanatogen  can 
be  added.     Meat  preparations  should  be  avoided  in  these  cases. 

In  cases  with  deficiency  of  hydrochloric  acid,  the  meats  are  not 
well  digested  and  should  be  given  in  smaller  quantities;  rice,  barley, 
and  tapioca  (strained)  or  in  purees,  and  mashed  potatoes  are  of 
service,  and  in  larger  amounts.  I  have  often  found  raw  eggs  beaten 
up  in  water  or  milk  of  great  service,  employing  at  times  six  to  eight 
daily.  The  milk  can  be  completely  or  partially  peptonized  to  lessen 
curd  formation.^ 

If  thirst  is  marked,  rectal  enemata  of  hot  normal  saline  solution 
are  indicated,^  and  in  very  severe  cases  the  stomach  may  be  given  a 
rest  and  nutritive  enemata  be  given  for  a  few  days. 

Sanatogen,  preferably  flavored,  tropon,  and  somatose  are  useful 
adjuncts,  given  in  divided  doses  in  the  broths.  If  anemia  is  pres- 
ent, iron  tropon  can  be  added,  oj  (4-0),  three  times  a  day.  Always 
peptonize  milk  if  given  by  enema. 

After  eating  the  patient  should  lie  down  for  from  one-half  an 
hour  to  an  hour,  preferably  on  the  right  side,  so  the  stomach  can 
empty  itself  more  readily. 

Mechanic  Support. — One  of  the  most  important  methods  of 
treatment  is  the  use  of  proper  support  to  the  organ,  and  the  ideal 
method  is  by  Rose's  adhesive  plaster  belt,  a  description  of  which  has 
been  given.  It  increases  intra-abdominal  pressure  and  the  stomach 
is  pushed  upward,  acting  in  effect  like  gastroplication.  Transillu- 
mination was  employed  in  one  case  (Fig.  150),  the  belt  applied,  and 
transillumination  again  carried  out  (Fig.  151). 

The  illustration  (Fig.  151)  shows  the  result,  the  lower  border  of 
the  stomach  being  elevated  4  inches.  This  belt  should  be  worn 
four  or  five  weeks  and  a  new  one  then  applied.  It  aids  in  the  evacua- 
tion of  the  stomach  contents.  Silk  abdominal  belts  may  be  sub- 
stituted, but  the  support  is  not  continuous  and  the  adhesive  strapping 
is  superior. 

General  Hydrotherapy. — External  douches — the  fan  douche 
and  also  the  Scotch  douche — applied  to  the  region^  of  the  stomach 
and  changing  the  temperature  of  the  water  has  been  serviceable 

1  With  the  precaution  noted,  milk  may  be  employed  in  the  cases  with  not  too 
marked  motor  insufficiency.  It  is  a  simple  matter  to  test  whether  it  leaves  the 
stomach  readily  or  not. 

2  Proctoclysis  is  of  value.  ^  ^n  adjustable  silk  belt  is  worn  in  this  event. 


332 


DISEASES    OF   THE    STOMACH   AND    INTESTINES 


in  some  cases.     Cold  compresses  and  cold  sponging  are  at  times 
useful. 

Local  Treatment  of  the  Stomach. — (i)  Lavage. — In  some  of  the 
milder  atonic  cases  proper  diet,  mechanical  support,  and  appropriate 
medication  may  suffice  without  or  with  occasional  lavage.  In  the 
more  severe  cases  lavage  is  indicated,  and  the  time  of  its  performance 
and  frequency  depend  upon  the  degree  of  dilatation  and  the  amount 
of  residuum  found  after  the  test  meal  (degree  of  motor  insufficiency). 


Fig.  150. — Dilatation  of  the  stom- 
ach. Transillumination  with  fluores- 
cein before  application  of  Rose's  belt 
(Case  i)  (Ward's  Island  Gastro-intes- 
tinal  Clinic,  Manhattan  State  Hospital). 


Fig.  151. — Dilatation  of  the  stom- 
ach, same  patient  (Case  i).  Trans- 
illumination with  fluorescein  after 
application  of  Rose's  belt.  By  accu- 
rate measurement  the  stomach  has 
been  elevated  and  the  lower  border  is 
4  inches  higher  than  it  was  before  the 
belt  was  applied.  The  lower  border 
now  lies  above  the  umbilicus  (Ward's 
Island  Gastro-intestinal  Clinic,  Man- 
hattan State  Hospital). 


If  there  is  not  immediate  im- 
provement if  lavage  is  omitted,  it 
must  be  added  to  the  treatment. 

If  a  large  amount  of  residuum 
is  present  after  a  test  meal  or  test  breakfast,  or  there  are  nervous 
symptoms,  or  in  the  morning  before  breakfast  a  residuum  is  present, 
lavage  should  be  carried  out. 

As  to  the  proper  hour  for  lavage,  I  believe  Riegel  holds  sound 
views,  and  my  own  experience  agrees  with  his;  if  the  residuum  is 
200  to  500  cc.  or  more  before  supper,  it  is  best  to  wash  the  stomach 
then  and  follow  with  a  light  meal;  if  this  is  not  done  the  organ  will 
contain  fermenting  food  during  the  night  which  will  increase  the 


CHRONIC    DILATATION    OF   THE    STOMACH  333 

atony.  If  food  is  present  before  breakfast  a  second  lavage  is  then 
indicated. 

The  washing  should  be  performed  with  the  patient  both  sitting 
and  lying  down,  so  as  to  remove  all  the  irritating  material.  The 
stomach  should  be  washed  until  the  return  is  clear. 

Daily  lavage  is  generally  necessary  at  first.  As  the  tone  of  the 
stomach  improves,  the  residuum  found  will  decrease  and  washing 
may  be  performed  less  often.  The  first  part  of  the  washing  may  be 
done  with  plain  warm  water,  though  normal  saline  solution  is 
preferable. 

I  have  found  milk  of  magnesia  (Phillips),  oij  (60.0)  to  i  quart 
(liter)  of  water,  excellent  for  the  preliminary  lavage.  It  is  well  to 
employ  antifermentatives  in  the  final  treatment,  such  as — 

Acid  salicylic i :  1000 

Sodium  salicylate 1:1 000 

Sodium  benzoate i :  1000 

Listerin 1 

Glycothymolin >oj  (4-o)  to  i  quart  (liter). 

Borolyptol J 

Resorcin  or \  gr.  15  to  30  (1.0-2.0)  to   i 

Boric  acid J       quart  (liter). 

(2)  Electricity. — ^The  intragastric  faradic  current  (preferably)  can 
be  employed  if  there  be  no  objection  on  the  part  of  the  patient, 
using  Lockwood's  instrument.  In  many  cases  the  percutaneous 
method  is  advisable. 

Static  electricity  is  claimed  to  be  of  value,  and  in  some  cases  to 
reduce  the  size  of  the  atonic  dilated  stomach. 

Massage  or  -vibratory  massage  are  of  service  to  tone  the  muscula- 
ture and  aid  in  emptying  the  stomach. 

(3)  The  stomach  douche  has  been  recommended  in  the  milder 
forms  to  stimulate  the  organ.  The  fluid  should  be  at  a  temperature 
of  95°  to  85°  F.  (gradually  reduced). 

If  hydrochloric  acid  is  diminished,  normal  salt  solution  may  be 
employed ;  if  HCl  is  increased,  then  use  silver  nitrate  i :  3000  to  i :  2000. 

-Bitter  remedies,  such  as  quassia  (fluidextract) ,  0.888  cc.  (111 15) 
to  1.77  cc.  (oss),  or  a  cup  of  quassia-water  (quassia  cup  filled  with 
water  and  allowed  to  set  for  half  an  hour) ;  or  hops  (fluidextract 
lupulin),  0.888  (TTLxv)  to  1.77  cc.  (.oss),  or  fluidextract  of  condurango, 
1.77  cc.  (oss)  to  3.54  cc.  (oj)  to  a  liter  of  water,  have  been  recommended 
for  lavage  as  a  stimulant,  but  I  see  no  special  value  in  their  use. 

The  stomach  spray  has  also  been  suggested  in  place  of  the  stomach 
douche,  but  it  possesses  the  disadvantage  of  injecting  considerable 
air. 

Medicines. — If  there  is  deficiency  of  hydrochloric  acid,  the 
stomachics  and  hydrochloric  acid  should  be  administered,  such  as 
are  employed  in  chronic  gastritis.  The  following  prescription  is 
often  valuable: 


334  DISEASES   OF   THE    STOMACH    AND   INTESTINES 

Acid  hydrochloric,  dilute  J ^^     ^   "     *^^   J-* 

Comp.  tinct.  cinchona 16.0  (oss) 

Aq.   destil q.  s.  ad.   125.0  (oiv). — M. 

Sig. — One  to  two  teaspoonfuls  in  a  wineglassful  of  water  t.  i.  d.  half  an  hour 
before  meals. 

If  there  is  hyperacidity,  magnesia  usta,  gr.  xv  to  oss  (1.0-2.0)  or 
more,  in  water  t.  i.  d.  an  hour  after  meals.  Or  milk  of  magnesia 
(Phillips),  5j  to  ij  (4.0-8.0),  in  water.     These  are  excellent  remedies. 

If  bicarbonate  of  soda  be  employed,  it  is  better  to  combine  it 
with  magnesia  usta,  equal  parts,  as  it  readily  generates  carbonic 
acid  gas. 

In  the  atonic  type  of  dilatation  I  have  always  been  inclined  to 
employ  nux  vomica  or  its  alkaloid  as  a  stimulant  to  the  musculature 
of  the  stomach,  even  though  hyperacidity  be  present,  which  is  rare; 
in  the  latter  event  combining  belladonna  with  the  nux,  as  a  pill, 
before  meals: 

"*■  Ext:  SadoZl'" } »^  ^-  i  (°-°-^'-»- 

or 

I^.     Strychnin gr.  eV  (0.00108) 

Atropin gr.  too  (0.00064).— M. 

If  nux  vomica  is  incorporated  in  the  stomachic  mixture,  it  should 
not  be  repeated.  If  the  tincture  of  nux  vomica  is  employed,  it  can 
be  gradually  increased  to  large  dose — oss  (2.0)  t.  i.  d. 

For  fermentation  and  intestinal  putrefaction  the  following  remedies 
are  of  service,  given  three  times  a  day  half  an  hour  to  an  hour  after 
meals:  Sahcylate  of  soda,  benzoate  of  soda,  ichthoform,  ichthalbin, 
bismuth  salicylate,  salol,  resorcin,  benzonaphtol,  bismuth  phenolate, 
or  bismuth  sulphocarbolate,  all  in  doses  of  gr.  v  (0.3)  each.  Urotropin, 
gr.  V  (0.3),  given  in  combination  with  sodium  benzoate,  gr.  v  (0.3),  in 
water  t.  i.  d.  after  meals  is  also  useful. 

I  have  found  resorcin  an  excellent  remedy,  alone  or  combined 
with  bismuth  subnitrate.  If  mould  is  present  the  creosote  prepara- 
tions as  suggested  by  A.  Rose  are  preferable,  such  as  beech  wood 
creosote,  Ttlj  (0.059  cc),  or  carbonate  of  creosote  (creosotal),  gr.  5 
(0.3),  three  times  a  day  after  meals. 

For  constipation  the  olive  oil  injections  at  night,  to  be  retained, 
Siv  (125  cc.)  to  I  pint  (500  cc.)  or  more,  as  suggested  by  Fleiner; 
massage,  electricity,  the  estabhshment  of  a  regular  hour  for  stool,  the 
administration  of  a  glass  of  water  on  rising,  and,  if  required,  the  use 
of  the  cascara  preparations  or  the  aloin  and  belladonna  pill,  or  one 
of  the  phenolphthalein  preparations,  such  as  phenolax,  at  night. 
The  saline  cathartics  are  objectionable. 

Gastrosuccorrhea  is  rare  in  the  atonic  type  of  dilatation.  In 
the  event  of  its  presence,  lavage  with  nitrate  of  silver  (i :  2000)  twice 


CHRONIC    DILATATION    OF   THE    STOMACH  335 

a  week  and  belladonna  tincture,  IfTlx  (0.592  cc.)  t.  i.  d.,  or  extract  of 
belladonna,  gr.  J  (0.022)  t.  i.  d.,  are  indicated.  For  further  treat- 
ment, the  chapter  on  this  subject  should  be  consulted. 

For  gastric  tetany,  which  may  occur  in  the  atonic  type  of  ectasy, 
but  which  is  a  rare  condition,  lavage  is  of  service,  but  gastro-enteros- 
tomy  is  indicated.  Moynihan  has  operated  on  14  cases  of  gastric 
tetany,  with  cures  in  all. 

Surgery. — In  atonic  ectasy,  when  no  improvement  occurs  under 
treatment  or  when  the  dilatation  is  of  great  degree  and  the  patient's 
condition  seems  to  be  getting  worse,  operation  is  indicated — prefer- 
ably drainage  of  the  stomach  by  gastro-enterostomy. 

Gastroplication — infolding  the  wall  of  the  stomach  and  sewing 
it  in  pleats — has  also  been  successfully  reported.  Coffey  has  sutured 
the  greater  omentum  to  the  abdominal  wall  and  thus  supported  the 
stomach  in  a  hammock.     He  reports  two  favorable  results. 

Treatment  of  Stenotic  Dilatation  (Benign  Stenosis) 

In  these  cases,  where  there  is  a  mechanical  obstruction  to  the  exit 
of  the  gastric  contents,  the  muscular  action  is  increased  during  the 
earlier  stages  and  hypertrophy  of  the  pyloric  end  of  the  stomach  is 
present;  later  the  fundus  and  body  become  distended  and  thinner. 
Gentle  massage  from  left  to  right,  or  vibratory  massage  by  the  same 
method,  the  patient  lying  on  the  right  side  and  the  manipulations 
being  performed  an  hour  or  two  after  meals,  may  aid  in  emptying 
of  the  stomach.  Electricity  is  of  slight  or  no  value.  I  have  seen  no 
permanent  benefit  from  these  methods  in  the  obstructive  type  of 
dilatation.  Olive  oil,  oij  to  iv  (60.0-125  cc),  administered  three 
or  four  times  a  day  before  meals  will  aid  the  passage  of  the  food 
through  the  stenosed  region,  and  Rose's  adhesive  plaster  belt  is  also 
of  service. 

The  diet  must  be  liquid  in  the  worst  cases  and  mushes  may  be 
employed  in  the  less  severe  types.  Raw  eggs,  six  to  eight  a  day, 
plenty  of  fat,  such  as  butter  and  cream,  sanatogen,  somatose,  and 
tropon,  are  all  of  service.  The  general  method  of  feeding  with  small 
frequent  meals  is  the  same  as  in  atonic  ectasy.  Improvement  in 
weight  must  be  secured.  Solid  food  is  objectionable.  "The  sour 
milks,  such  as  bacillac,  lactone-buttermilk,  kefir,  matzoon,  and  kum^^ss, 
administered  after  the  manner  described  in  atonic  ectasy,  are  of 
value."  lyavage  is  always  necessary,  and  for  the  attacks  of  spasmodic 
pain  is  the  most  rapid  method  to  secure  relief.  As  hyperacidity  is 
present,  alkalis  are  indicated  to  correct  this  condition,  as  in  hyper- 
chlorhydria. 

Tincture  of  belladonna  in  large  doses,  10  to  15  drops  t.  i.  d.,  will 
often  relieve  spasm  and  pain,  also  the  application  of  heat. 

Vomiting.— For  vomiting  lavage  is  indicated,  followed  for  several 
days  by  rectal  feeding  and  then  commencing  with  a  small  amount 
of  liquid  nourishment. 


336  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Rectal  injections^  of  normal  saline  solution,  oviij  to  Oj  (250- 
500  cc),  may  be  indicated  to  relieve  thirst  and  collapse. 

Thiosinamin,  gr.  v  (0.3)  doses  t.  i.  d.  by  mouth,  or  gr.  iij  (0.2) 
doses  in  15  per  cent,  alcoholic  or  10  per  cent,  glycerinated  solution 
by  hypodermic,  may  prove  of  service  in  fibrous  contractures  of  the 
pylorus. 

Gastrosuccorrhea  may  occur  in  cases  when  there  is  an  ulcer  with 
stenosis  at  the  pylorus  and,  rarely,  hemorrhages.  Temporary  treat- 
ment as  for  hemorrhage  of  gastric  ulcer  is  indicated,  and  then 
surgical  procedure.  The  treatment  for  gastrosuccorrhea  is  described 
in  the  chapter  on  that  subject. 

Gastric  tetany  may  be  a  complication  for  which  lavage  is  indicated 
temporarily,  and  then  operation  (gastro-enterostomy). 

I  have  seen  cases  of  ectasy  from  benign  stenosis  lose  75  pounds 
in  weight  and  regain  50  to  60  pounds  under  treatment,  and  ultimately 
relapse  and  come  to  operation.  I  have  treated  many  so-called 
brilliant  cures  by  specialists,  the  ultimate  results  being  the  same. 
These  patients,  even  at  the  best,  tend  to  become  chronic  invalids 
and  always  require  treatment.  The  best  physician  for  these  cases 
is  the  surgeon. 

If  the  cause  of  the  stenosis  lies  external  to  the  pylorus,  bands, 
adhesions,  etc.,  can  be  separated.  If  it  is  intrinsic,  resection  of  the 
pylorus  can  be  performed  in  suitable  cases,  or  drainage  by  gastro- 
enterostomy. The  latter  is  usually  the  operation  of  selection.  Divul- 
sion  I  do  not  approve. 

I  have  seen  a  patient  gain  100  pounds  in  weight  in  eight  weeks 
after  gastro-enterostomy,  and,  from  being  a  confirmed  invalid, 
restored  to  perfect  health. 

Malignant  Stenosis 

In  these  cases  early  radical  operation  is  indicated,  as  described 
under  Cancer  of  the  Stomach;  otherwise,  palliative  gastro-enter- 
ostomy. If  operative  procedure  be  refused,  then  diet,  lavage,  and 
the  treatment  laid  down  under  Carcinoma  Ventriculi. 

COMPLICATIONS   OF   CHRONIC  ECTASY 
Gastric  Tetany 

Tetany  is  characterized  by  peculiar  bilateral  tonic  spasm  of  the 
extremities,  either  paroxysmal  or  continued. 

Pathology. — In  all  cases  there  is  dilatation  of  the  stomach  of  a 
high  degree,  due  generally  to  stenosis  of  the  pylorus  or  the  duodenum ; 
frequently  the  result  of  an  ulcer;  rarely  from  carcinoma. 

Gastrosuccorrhea  has  been  associated  with  it  in  some  cases. 
Tetany  has  also  been  reported  with  acute  ectasy  and  in  atonic  ectasia. 

Etiology. — There  are  three  theories  as  to  its  cause: 
1  Proctoclysis  is  of  service. 


COMPLICATIONS    OF    CHRONIC    ECTASY  337 

(i)  Kiissmaul  and,  later,  Fleiner  believed  its  symptoms  are  due 
to  the  great  loss  of  fluid  in  the  system,  the  thickening  of  the  blood, 
and  the  consequent  drying  of  the  tissues. 

(2)  Friederick  Miiller  and  Germain  See  consider  it  to  be  the  result 
of  some  reflex  action,  as  Miiller  brought  on  an  attack  by  tapping  the 
epigastric  region.  Riegel  has  observed  it  on  passing  the  stomach- 
tube  ;  and  it  has  also  occurred  in  cases  of  intestinal  worms. 

(3)  The  third  theory  explains  it  on  the  ground  of  auto-intoxica- 
tion, since  fermentation  and  putrefaction  are  present  in  the  stomach. 

This  last  is  probably  correct,  as  the  cases  have  been  benefited 
by  lavage  and  cured  by  stomach  drainage  (gastro-enterostomy). 

Amato  reports  a  case  of  gastric  tetany  with  death.  He  has 
introduced  fermenting  materials  into  the  stomachs  of  animals  and 
produced  dyspnea,  myosis,  muscular  contraction,  and  trismus. 
The  liver  and  pancreas  (post  mortem)  showed  lesions,  such  as  are 
usually  found  in  poisonings  and  intoxications. 

Symptoms. — There  are  tonic  and  clonic  bilateral  spasms,  which 
appear  suddenly  and  are  generally  confined  to  the  extremities,  the 
flexor  muscles  being  chiefly  affected.  The  fingers  are  bent  at  the 
metacarpophalangeal  joint,  extended  at  the  terminal  joints,  being 
pressed  close  together,  and  the  thumb  is  contracted  into  the  palm  of 
the  hand.  The  wrists  are  flexed,  the  elbows  bent,  and  frequently 
the  arms  are  folded  over  the  chest.  The  knees  are  bent,  the  feet 
extended,  and  the  toes  adducted. 

In  severe  cases  there  may  be  trismus  and  the  angles  of  the  mouth 
are  drawn  up.     There  is  sometimes  edema  of  the  hands  and  feet. 

The  spasms  are  usually  paroxysmal  and  last  for  a  variable  time. 
The  eyes  may  be  turned  up. 

In  the  acute  attack  there  may  be  a  rise  of  temperature  and 
elevation  of  the  pulse.  In  some  cases  there  may  be  involvement 
of  the  muscles  of  the  back  and  of  the  thorax,  with  dyspnea  and 
cyanosis. 

The  attack  may  be  acute,  from  a  few  minutes  to  several  hours, 
but  there  may  be  some  stiffness  and  contraction  lasting  several 
weeks. 

Diagnosis. — There  are  certain  diagnostic  features: 

(i)  ''Trousseau's  Symptom." — As  long  as  the  attack  is  not  over, 
the  paroxysms  may  be  produced  by  compressing  the  affected  parts, 
either  in  the  direction  of  their  principal  nerve-trunk  or  over  their 
blood-vessels,  so  as  to  impede  the  venous  or  arterial  circulation. 

(2)  "Chvostek's  Symptom." — There  is  an  increase  in  the  mechanical 
excitability  of  the  motor  nerv^es.  A  slight  tap  over  the  facial  nerve 
will  throw  the  muscles  to  which  it  is  distributed  into  active  con- 
traction. 

(3)  "Erb's  Sign." — The  electric  irritability  of  the  motor  nerves, 
to  the  galvanic  current  especially,  is  increased. 

(4)  "Hoffmann's  Sign." — Heightened  excitabiUty  of  the  sensory 
22 


338  'DISEASES    OF   THE    STOMACH   AND   INTESTINES 

nerves.     The  slightest  pressure  may  cause  paresthesia  in  the  region 
of  distribution. 

The  prognosis  of  tetany  is  extremely  bad. 

Frequency. — Moynihan  believes  it  to  be  not  so  very  rare,  and 
reports  14  cases  in  which  gastro-enterostomy  was  performed,  with 
a  cure  in  each  case ;  though  some  claim  only  30  to  40  cases  are  re- 
ported. 

Tetany-like  attacks  with  epileptiform  attacks  are  more  frequent, 
and  will  be  referred  to  under  Epilepsy. 

Treatment. — Bromids,  and  even  chloroform  inhalation  during 
the  acute  attack.     Lavage  is  beneficial. 

The  chief  indication  is  drainage  of  the  stomach  by  gastro- 
enterostomy. 

REFERENCES 

1.  Smith,  Med.  Record,  1900,  Iviii,  910. 

2.  Dujardin-Beaumetz,  L'Union  Medicale,  1884,  Nos.  15  and  18. 

3.  Strong,  Boston  Med.  and  Surg.  Journal,  1902,  cxlvii,  561,  597. 

4.  Simpson,  Pract.,  1900,  Ixv,  283. 

5.  Kussmaul,  Deutsches  Archiv.  f.  klin.  Med.,  1869,  Bd.  6. 

6.  Moynihan,  Pract.,  1903,  Ixx,  354. 

7.  Bouveret,  Rev.  de  Medicine,  1892,  p.  48. 

8.  Ewald,  Berlin,  klin.  Wochenschrift,  1894,  No.  2. 

9.  Fleiner,  Arch.  f.  Verdauungskrankheiten,  Bd.  1,  Heft.  3. 

10.  Einhorn,  Diseases  of  the  Stomach. 

11.  Amato,  La  Riforma  Med.,  Feb.  4,  1903. 

12.  E-  Neumann,  Deutsche  Klinik,  1861. 

13.  Boas,  loG.  cit.,  107,  and  others. 

CONVULSIONS— EPILEPSY 

Epileptic  seizures  occur  both  in  cases  of  chronic  ectasy  and  in 
other  affections  of  the  stomach.  I  have  a  case  at  present  under 
observation  at  the  Manhattan  State  Hospital  who  suffered  from 
repeated  attacks  of  epilepsy,  140  seizures  a  month.  There  is  dila- 
tation of  the  stomach,  with  ptosis  and  hypochlorh^^dria.  For  the 
last  two  years,  while  having  occasional  lavage,  dietetic  treatment 
with  medication  directed  to  the  stomach,  no  bromids,  she  has  had  no 
attacks,  except  for  the  period  of  a  week,  a  year  and  a  half  ago,  when 
the  treatment  was  omitted.  At  the  same  institution  there  is  another 
patient  with  atonic  ectasia  and  hypochlorhydria,  who  had  frequent 
epileptic  attacks  and  who  has  had  no  seizures  for  over  a  year,  as  a 
result  of  treatment  directed  to  the  gastro-intestinal  tract. 

I  have  reported  a  case  of  hyperchlorhydria,^  with  epileptic 
seizures,  apparently  cured  by  appropriate  treatment;  and  cases  of 
dementia  paralytica  with  chronic  ectasy,  in  which  the  convulsions 
were  diminished  under  treatment  and  the  high  temperatures  returned 
to  normal.  I  have  also  seen  tetany-like  convulsions  in  a  case  of 
dementia  prsecox,  with   gastroptosis  and   marked   ectasy,   improve 

^  Observations  on  the  Relation  of  the  Gastro-intestinal  Tract  to  Nervous 
and  Mental  Diseases,  reported  April  17-21,  1905,  American  Medicopsychological 
Association,  and  in  their  proceedings. 


CONVULSIONS — EPILEPSY  339 

after  treatment  of  the  stomach.  Salt-free  diet,  the  avoidance  of 
meat,  open  air,  and  treatment  appropriate  to  the  gastric  findings 
in  each  case  are  indicated. 

In  conclusion  I  cannot  recommend  too  highly  the  sour-milk 
diet  in  the  treatment  of  these  cases.  Matzoon,  kumyss,  kefir,  or  the 
lactone-buttermilk  can  be  employed  after  the  manner  indicated  under 
Atonic  Ectasy.  I  have  found  Wm.  H.  Thomson's  formula  for  the 
preparation  of  matzoon  of  great  value.     It  is  as  follows : 

"  I.  Place  half  a  cake  of  yeast  in  i  pint  (500  cc.)  of  fresh  milk  in 
a  pitcher  covered  with  a  towel  in  a  warm  place  for  twelve  hours ;  then 

"  2. ,  Add  to  this  i  quart  (liter)  of  milk  and  keep  in  a  warm  place 
for  twelve  hours ;  then 

"3.  Take  i  pint  (500  cc.)  of  No.  2,  add  to  it  i  quart  (liter)  of 
milk  and  keep  in  a  warm  place  for  twelve  hours ;  then 

"4.  Take  i  pint  (500  cc.)  of  No.  3,  add  to  it  i  quart  (Uter)  of 
milk  and  keep  in  a  warm  place  for  twelve  hours. 

"This  makes  ij  quarts  (1500  cc.)  of  matzoon,  the  entire  process 
occupying  forty-eight  hours. 

"  One  quart  (liter)  of  this  can  be  administered  in  divided  doses 
daily,  breaking  in  it  stale  bread  or  crackers  and  eating  it  with  a 
spoon.  The  remaining  pint  (500  cc),  with  the  addition  of  i  quart 
(liter)  of  milk  at  the  end  of  twelve  hours,  will  furnish  i^  quarts  (1500 
cc.)  of  matzoon.  Fresh  matzoon  can  be  made  daily  from  the  former 
pint  (500  cc.)  of  mother  matzoon  for  about  two  weeks,  when  the 
process  must  be  started  over  again.  If  larger  quantities  are  to  be 
used,  I  quart  (liter)  of  No.  2  can  be  used  with  2  quarts  (liters)  of  milk, 
and  so  on." 

This  method  has  been  extensively  employed  by  Thomson  and  the 
author  in  feeding  our  epileptics.  One  can  also  use  oiv  to  vj  (125- 
185  cc.)  of  the  ordinary  bottled  matzoon  to  i  quart  (liter)  of  milk, 
which  will  produce  matzoon  if  kept  twelve  hours  in  a  warm  place. 
From  this  daily  matzoon  can  be  made  from  each  previous  supply 
for  about  a  week,  when  a  fresh  bottle  must  be  employed. 


CHAPTER  XVI 


ANOMALIES  IN  THE  POSITION  AND  FORM  OF  THE 
STOMACH— HOUR-GLASS  STOMACH— DISLOCA- 
TIONS—GASTROPTOSIS 

Anomalies  of  form  are  frequently  congenital.  Fore-stomach  is 
a  dilatation  of  the  lower  end  of  the  esophagus  immediately  above  the 
diaphragm.  Antrum  cardiacum  is  a  sacculated  diverticulum  of 
the  esophagus  situated  below  the  diaphragm.  In  some  cases  no 
symptoms  are  present;  in  others  food  becomes  lodged  and  causes 
serious  results.  Megalogastria  is  a  congenital  or  acquired  large 
stomach  with  normal  functions.  Microgastria  is  an  abnormally  small 
stomach  with  normal  functions.  Angustatio  ventriculi  is  an  ex- 
tremely small  stomach  due  to  stricture  of  the  cardia  or  esophagus  or 
cirrhosis  ventriculi. 

Congenital  Narrowing  of  the  Pylorus. — This  condition  is  due 
to  hypertrophy  of  the  circular  muscles  of  the  pylorus.  It  may  be 
of  so  severe  a  type  that  ingestion  of  food  may  be  impossible  and  the 
infant  die  within  a  few  days  after  birth.  In  milder  cases  chronic 
ectasy  may  result. 

HOUR-GLASS  STOMACH 

This  condition  may  be  congenital,  but  is  more  frequently  acquired. 
The  stomach  has  a  peculiar  sacculated  outline,  and  is  divided  into 

two  parts — the  cardiac  and  pyloric  (Fig. 
152).  In  some  cases  the  cardiac  sac  is 
larger,  in  others,  the  pyloric. 

Etiology. — Cicatrized  tissue  contrac- 
tion following  an  ulcer;  less  frequently 
peritonitic  adhesions,  corrosive  gastritis, 
and  carcinoma  are  causes.  Slight  forms 
may  produce  no  characteristic  symptoms. 
In  advanced  cases  the  division  may  be 
recognized.  By  the  ingestion  of  bismuth 
and  the  use  of  the  fluoroscope  this  con- 
dition can  be  demonstrated. 

The  following  diagnostic  points  have 
been  given  by  Moynihan : 

With  lavage,  part  of  the  fluid  is  lost;  if 
the  stomach  is  washed  clean,  a   sudden 
reappearance  of  the  stomach  contents  takes  place,  "paradoxical  dila- 
tation"; when  the  stomach  has  been  apparently  emptied,  a  splashing 
sound  may  be  elicited  by  palpation  of  the  pyloric  segment ;  after  dis- 

340 


Fig.  152.- 


-Hour-glass  stom- 
ach. 


GASTROPTOSIS — ENTEROPTOSIS — GLENARD's    DISEASE  34 1 

tending  the  stomach,  a  change  in  the  position  of  the  distention  tumor 
may  be  seen  in  some  cases.  Gushing,  bubbhng,  or  sizzHng  sounds 
are  heard  on  dilatation  with  carbonic  acid  gas  at  a  point  distinct 
from  the  pylorus.  In  some  cases,  when  both  parts  are  dilated, 
two  tumors  with  a  notch  or  sulcus  between  are  apparent  to  sight 
and  touch.  On  both  sides  of  the  furrow  there  will  be  a  loud  tym- 
panitic sound  which  cannot  be  elicited  in  the  middle. 

Stockton  finds  that  if  the  first  part  of  the  stomach  is  aspirated, 
after  manipulation,  it  is  sometimes  possible  to  force  from  the  second 
into  the  first  portion  a  gastric  juice  of  different  quality.  Operative 
procedure  is  the  only  method  of  cure. 

DISLOCATION  OF  THE  STOMACH 

The  fundus  may  be  dislocated  upward.     Among  the  causes  are: 

Absorption  of  a  pleuritic  exudate  on  the  left  side ;  after  contraction 
of  the  lung  or  any  process  which  is  accompanied  by  upward  dislocation 
of  the  diaphragm;  excessive  distention  of  the  abdominal  cavity, 
forcing  the  diaphragm  upward,  such  as  from  pregnancy,  ascites, 
tumors,  and  meteorism ;  diaphragmatic  hernia. 

The  cardiac  end  of  the  esophagus  may  become  bent.  Lateral 
dislocation  is  rare,  and  may  be  caused  by  tumors  of  the  spleen, 
distended  colic  flexure,  or  lateral  pressure  from  an  enlarged  liver. 
As  a  rule,  the  latter  forces  the  stomach  downward. 

Downward  dislocation  (gastroptosis)  is  the  common  form. 

GASTROPTOSIS— ENTEROPTOSIS—GLENARD'S  DISEASE 

(Synonyms. — Gastroptosia  (Rose);  Visceroptosis;    Splanchnoptosis;    Abdominal 
Relaxation  or  Atonia  Gastrica  (Rose) ;  Atony  of  the  Third  Degree.) 

Definition. — Gastroptosis  may  be  defined  as  a  prolapse  or 
downward  displacement  of  the  stomach,  right  kidney  or  both 
kidneys,  and  other  organs  of  the  abdominal  cavity,^  which  may  be 
associated  with  disturbances  of  the  gastro-intestinal  tract  and  pelvic 
organs,  together  with  various  nervous  symptoms. 
-Nephroptosis  is  a  stigma  of  gastroptosis. 

Introduction. — I  here  use  the  term  "gastroptosis"  with  the 
usual  definition  (ptosis  of  the  stomach),  though  Rose  has  shown  it 
correctly  means  descent  of  the  belly  (splanchnoptosis).  The  reader 
must  remember  that  gastroptosis  is  a  quite  frequent  condition,  and 
that  it  may  be  accidentally  discovered  in  some  cases  which  have  no 
symptoms  whatever.  On  the  other  hand,  there  are  various  degrees 
of  ptosis  of  the  stomach,  in  some  of  which  the  symptoms  are  rather 
mild  in  character,  while  in  others  there  may  be  the  symptoms-com- 
plex of  Glenard's  disease. 

It  is  not  the  position  of  the  lower  border  of  the  stomach  which 
constitutes  a  ptosis,  but  that  of  the  upper  border;  with  the  relaxation 
1  Ptosis  of  the  heart  may  also  occur. 


342  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

of  the  suspensory  ligaments  of  the  stomach  the  lesser  curvature 
sinks  as  well  as  the  greater,  and  we  may  have  varying  degrees  of 
ptosis,  from  moderate  obliquity  of  the  upper  border  to  a  vertical 
stomach ;  while  on  the  other  hand,  the  entire  organ  may  sink  and  give 
the  crescentic  form  of  gastroptosis.  The  determination  of  the  lower 
border  alone  is  not  diagnostic,  since  it  may  merely  be  evidence  of  a 
dilated  stomach.  Hundreds  or  even  thousands  of  cases  of  nephropto- 
sis have  been  reported  with  dilated  stomachs,  the  dilatation  being 
imputed  to  pressure  of  the  kidney  on  the  duodenum,  and  no  investi- 
gation has  been  made  of  the  position  of  the  lesser  curvature. 

From  my  own  experience,  I  do  not  hesitate  to  say  that  movable 
kidney  (nephroptosis),  with  the  lower  border  of  the  stomach  lower 
than  normal,  is  diagnostic  of  gastroptosis.  Dilatation  of  the  stomach^ 
is  often  associated  with  gastroptosis,  but  kidney  pressure  on  the 
duodenum,  in  my  opinion,  has  no  bearing  as  to  its  production. 
Furthermore,  treatment  for  gastroptosis  will  generally  cure  this 
condition.  Ptosis  of  the  stomach  in  some  of  these  cases  may  be  of 
extremely  mild  type. 

Anatomic  Considerations.— It  is  necessary  to  briefly  allude  to 
certain  anatomic  features.  The  liver,  as  we  know,  is  suspended 
from  the  diaphragm  by  ligaments  derived  from  the  peritoneum. 
The  cardiac  end  of  the  stomach  is  held  quite  fixedly  in  position  by  the 
esophagus,  and  there  is  a  peritoneal  attachment  to  the  diaphragm  at 
this  point,  the  gastrophrenic  ligament.  In  this  location  the  stomach 
lies  in  close  relation  to  the  diaphragm,  while  the  lesser  curvature  is 
suspended  from  the  liver  by  the  lesser  omentum  (gastrohepatic). 
The  spleen  lies  in  close  relation  to  the  diaphragm,  being  attached 
thereto  by  ligaments  (processes  of  the  peritoneum),  and  to  the 
stomach  by  the  gastrosplenic  omentum. 

It  is  thus  readily  understood  how  compression  of  the  lower  part 
of  the  thorax  or  effusions  above  the  diaphragm  may  mechanically 
force  down  the  latter  and  produce  ptosis  of  organs  so  closeh^  asso- 
ciated.    The  descent  of  the  intestines  is  a  natural  accompaniment. 

A  tumor  of  the  p^dorus  may  cause  ptosis  of  the  stomach,  and 
prolapse  of  the  transverse  colon  and  of  the  other  viscera  follow. 

On  the  other  hand,  a  severe  type  of  dilatation  of  the  stomach 
may  be  followed  by  ptosis  of  the  organ  and  then  general  visceroptosis. 
These  primary  types  of  gastroptosis  are  not  so  very  frequent. 

The  transverse  mesocolon  surrounds  the  transverse  colon  and 
connects  it  with  the  back  of  the  abdomen  at  the  spine.  The  trans- 
verse colon  is  attached  to  the  abdominal  surface  of  the  eleventh  rib 
on  each  side  by  a  fold  of  peritoneum.  As  the  colon  passes  across 
the  abdomen  it  sags  somewhat,  presenting  a  slightly  concave  surf  ace 
superiorly.  Glenard,  whom  we  must  justly  credit  as  the  first  to 
describe  splanchnoptosis  as  a  pathologic  entity,  believes  enteroptosis 
(ptosis  of  the  transverse  colon)  to  be  the  starting-point.     He  thinks 

1  This  combination  has  been  found  in  cases  at  the  Manhattan  State  Hospital. 


GASTROPTOSIS — ENTEROPTOSIS — GLENARD'S    DISEASE  343 

the  transverse  colon  is  fastened  to  the  pyloric  end  of  the  stomach  by 
a  band  (ligament)  and  that  the  hepatic  flexure  first  sags,  followed 
by  the  transverse  colon,  causing  thus  a  sharp  flexion  at  the  attach- 
ment of  the  ligament,  and  a  hindrance  to  the  progress  of  the  intestinal 
contents,  with  resulting  accumulation  in  the  ascending  and  transverse 
colon.  From  the  point  of  stenosis  the  transverse  colon  passes  down- 
ward diagonally  across  the  abdomen  as  a  hard  cord-like  mass  (corde 
colique  transverse). 

The  sagging  of  the  transverse  colon  exercises  traction  on  the 
pylorus  and  omentum,  thus  causing  descent  of  the  stomach  and 
liver.  The  descent  of  the  hepatic  flexure,  he  believes,  causes  traction 
on  the  parietal  peritoneum  and  encourages  ptosis  of  the  right  kidney. 
The  gastro-intestinal  tract,  he  noted,  was  suspended  in  the  form  of 
loops,  six  in  number,  by  means  of  ligaments;  and  he  believed  in  the 
possibility  of  too  great  a  bend  at  such  an  acute  angle,  that  it  might 
cause  a  partial  obstruction  to  the  passage  of  the  contents.  This 
might  occur  at  the  gastroduodenal,  the  duodenojejunal,  transverse 
colon,  or  sigmoidorectal  curves. 

The  gastroduodenal  and  transverse  colon  ligaments  Glenard 
holds  to  be  the  weakest,  and  if  they  give  way,  with  resulting  ptosis 
of  the  intestine,  increased  traction  and  angulation  is  produced  at 
the  next  fixation  point,  causing  an  enterostenosis. 

Glenard  found  the  transverse  colon  displaced  and  stenosed  in 
numerous  autopsies,  and  was  the  first  to  realize  that  many  cases  of 
so-called  nervous  dyspepsia  were  dependent  upon  these  abnor- 
malities. 

Riegel  has  demonstrated  that  the  hepatic  flexure  is  not  dislocated 
downward  in  the  majority  of  cases,  and  Glenard's  explanation  I 
hardly  believe  tenable,  as  there  are  other  very  important  factors 
which  have  a  bearing.  A  tumor,  however,  of  the  transverse  colon 
or  adhesions  may  produce  primary  enteroptosis. 

We  must  remember  there  is  one  type  of  case,  a  congenital  con- 
stitutional defect,  the  patient  with  long  narrow  thorax,  who  suffers 
from  splanchnoptosis. 

The  major  number  of  cases  of  gastroptosis,  however,  are  acquired 
from  various  causes;  and  in  my  opinion  the  development  of  the 
prolapse  of  the  various  organs  generally  occurs  synchronously,  the 
stomach,  right  kidney,  and  transverse  colon  most  frequently  pro- 
lapsing together;  while  in  other  cases  the  left  kidney  or  the  rest 
of  the  viscera  may  descend  in  addition. 

These  following  are  the  prominent  factors  which  have  a  marked 
bearing  in  preserving  the  proper  position  of  the  viscera: 

(i)   The  abdominal  muscles. 

(2)    The  maintenance  of  normal  intra-abdominal  pressure. 

(i)   Abdominal  Muscles. — In  an  interesting  article,  A  Rose'  calls 

1  Surgery,  Gynecology,  and  Obstetrics,  November,  1906,  Physiology  and 
Pathology  of  the  Abdominal  Muscles. 


344  DISEASES  OF  the;  stomach  and  intestines 

attention  to  the  fact  that  in  addition  to  the  usual  functions  described 
in  the  text-books,  in  assisting  expulsion  of  the  fetus,  bowel  action, 
urination,  and  vomiting,  the  abdominal  muscles  aid  in  the  preserva- 
tion of  the  physiologic  position  of  the  abdominal  organs.  The  cross- 
wise arrangement  of  the  external  and  internal  oblique  and  trans- 
versalis  muscles — supported  by  the  recti — effect  a  narrowing  of  the 
abdominal  cavity  and  prevent  visceral  ptosis. 

Groddeck,  of  Baden-Baden,  has,  moreover,  described  the  mechan- 
ical influence  of  healthy  muscle,  by  the  alternate  contraction  and  ex- 
pansion, in  assisting  the  circulation  of  the  blood  and  lymph,  and 
an  atonic  condition  of  the  abdominal  musculature  would  certainly 
interfere  with  the  maintenance  of  the  normal  relations  between  the 
extra-  and  intra-abdominal  circulation.  Moreover,  clinically,  simple 
inspection  will  differentiate  between  normal  conditions  and  the 
typic  "pot-belly"  of  the  gastroptosis  patient.  Acute  or  wasting 
disease  may  also  cause  changes  in  the  muscles. 

(2)  Intra-abdominal  Pressure. — Normal  abdominal  muscles  also 
maintain  the  normal  intra-abdominal  pressure  necessary  to  preserve 
the  position  of  the  viscera. 

Walkow^  has  made  a  very  exhaustive  study  of  this  question  and 
has  demonstrated,  for  example,  on  the  cadaver,  with  the  upper  part 
of  the  trunk  elevated  (the  reversed  Trendelenburg  position),  that 
after  abdominal  section  mobility,  of  varying  degrees,  of  the  kidney  is 
found,  which  did  not  previously  exist. 

Stiirmdorf  has  found  similar  results  after  laparotomy  on  the 
living. 

Clinically,  changes  in  the  intra-abdominal  pressure,  the  result  of 
childbirth  or  tapping  for  ascites,  have  resulted  in  the  production  of 
splanchnoptosis,  the  thinned  and  distended  musculature  of  the 
abdomen  also  being  a  factor. 

Rapid  loss  of  weight  from  emaciation  and  absorption  of  omental 
fat  is  another  example. 

Nephroptosis. — Movable  kidney,  in  probably  95  per  cent,  of 
cases  in  my  own  experience,  is  one  of  the  stigmata  of  gastroptosis. 
The  congenital  type,  with  long  mesonephron,  or  those  cases  due  to 
traumatism,  are  comparatively  few  in  number. 

The  right  kidney  has  a  longer  pedicle  and  lies  lower  on  account 
of  the  liver. 

Stiirmdorf  refers  to  certain  skeletal  deformities  as  influencing 
the  shape  of  the  bony  receptacle  for  the  kidneys,  and  which  in  some 
cases  predisposes  to  prolapse;  but  gastroptosis  is  associated  with 
these  same  conditions. 

It  has  been  claimed  that  there  is  a  nephrocolic  ligament  connecting 

the  kidneys  to  the  ascending  and  descending  colon,  and  that  traction 

of  the  colon  may  influence  its  descent.     Reversed  peristaltic  action 

occurring  intermittently  in  the  ascending  colon,  which  does  not  take 

1  Medical  Record,  January  13,  1906. 


GA5TROPTOSIS— ENTEROPTOSIS — GLENARD's    DISEASE  345 

place  in  the  descending,  is  believed  to  have  an  influence,  and  the 
peritoneum  over  the  left  kidney  is  said  to  be  thicker.  The  fact  that 
the  tail  of  the  pancreas  lies  in  front  of  the  left  kidney  seems  to  me  to 
have  some  bearing  on  the  question.  Absorption  of  the  fatty  capsule 
is  probably  another  factor. 

The  peculiar  position  of  the  right  kidney  and  lessening  of  intra- 
abdominal pressure  seem  to  be  the  chief  causes  of  its  more  frequent 
descent. 

With  gastroptosis  we  have  also  a  relaxation  of  the  gastro-intestinal 
musculature  and  of  all  the  peritoneal  ligaments.  Changes  in  the  posi- 
tion of  the  stomach  and  in  its  secretory  and,  at  times,  in  its  motor 
functions  account  for  the  gastric  disturbances.  The  secretory  func- 
tion one  might  expect  to  be  influenced  by  circulatory  disturbances 
following  displacement  of  the  organ. 

Associated  are  changes  in  the  position  of  the  duodenum  produc- 
tive of  stasis,  and  which  readily  account  for  gall-bladder  symptoms 
simulating  stone,  so  often  attributed  to  nephroptosis.  Similar 
disturbances  in  the  intestine,  constipation,  diarrhea,  mucous  colic, 
or  chronic  appendicitis^  can  thus  be  accounted  for.  There  is  a  relaxa- 
tion of  the  broad  ligaments  and  with  it  ovarian  and  uterine  descent, 
and  even  descent  of  the  pelvic  floor,  with  dysmenorrhea  and  various 
pelvic  symptoms. 

Occasionally  Dietl's  crisis  from  torsion  of  the  kidney  pedicle 
and,  rarely,  nephritis  or  hydronephrosis  occur.  More  rarely  the  kid- 
ney may  become  adherent  to  the  gall-bladder  or  appendix.  In  addi- 
tion, circulatory  disturbances  and  marked  neurasthenia,  the  latter 
due  chiefly,  I  believe,  to  auto-intoxication,  are  present;  and  from  the 
severe  type  of  splanchnoptosis  we  have  the  symptoms-complex  of 
Glenard's  disease — all  of  which  the  "kidney  experts"  attribute  to 
nephroptosis. 

Etiology. — We  must  remember  that  the  vertical  stomach  is  the 
fetal  position  of  the  organ  and  every  infant  is  born  with  it  in  this 
position.  After  a  few  weeks  or  months,  through  the  weight  of  the 
food  and  the  action  of  the  diaphragm,  the  position  of  the  stomach 
becomes  normal.  Occasionally  it  may  remain  vertical,  but  I  believe 
this  is  true  more  especially  in  those  suffering  from  the  congenital 
constitutional  defect,  to  which  I  shall  refer. 

The  causes  of  gastroptosis  may  be  divided  into  congenital  and 
acquired : 

I.  Congenital  constitutional  defect,  the  long  narrow  thorax, 
with  the  diaphragm  and  liver  pushed  down.  In  these,  splanchnopto- 
sis is  a  constitutional  defect.  Stiller's  floating  tenth  rib  is  usually 
present.  2.  Other  skeletal  deformities,  spinal  curvature,  rickets,  ky- 
phosis, kyphoscoliosis.  3.  Intrathoracic  pressure  on  the  diaphragm 
from  effusions,  tumor,  etc.     4.  Tumors  of  the  liver.     5.  Leukemic 

1 1  do  not  agree  with  Edebohls'  theory  of  compression  of  the  superior  mesen- 
teric vein  by  the  kidney  as  a  cause  of  congestion  of  the  appendix. 


346  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

enlargements  of  the  spleen.  6.  Tumor  of  the  pylorus  or  adhesions 
(gastric).  7.  Tumor  of  the  colon  or  adhesions.  8.  Chronic  dilata- 
tion of  the  stomach.  9.  Compression  of  the  thorax  by  tight  lacing, 
poor  corsets,  tight  waist-bands,  etc.  10.  Relaxation  of  the  abdom- 
inal muscles  and  diminution  of  intra-abdominal  pressure.  This  may 
result  from  rapid  emaciation  in  acute  disease,  with  degeneration  of 
the  muscular  tissue ;  or  the  same  condition  in  longer  chronic  wasting 
disease,  or  from  loss  of  weight  and  muscular  tone  from  any  cause. 

Landau's  disease,  splanchnoptosis  following  confinement,  is 
fairly  frequent.  Emptying  of  the  uterus  produces  a  sudden  diminu- 
tion in  intra-abdominal  tension,  and  the  tendency  of  the  viscera  is 
to  fill  the  vacuum  previously  occupied  by  the  uterus.  The  abdominal 
walls  are  lax  and  thin  from  uterine  pressure.  The  accoucheur  is 
often  to  blame  for  not  properly  supporting  the  relaxed  abdomen. 

Tapping  of  ascites,  with  removal  of  all  the  fluid,  may  produce  a 
similar  condition;  or  removal  of  large  tumors. 

Sex. — Meynert  found  in  50  girls,  age  twelve,  50  per  cent,  gastropto- 
sis,  and  about  80  per  cent,  females  in  his  gynecologic  clinic  to  5  per 
cent,  males  among  adults. 

From  the  study  of  various  statistics  it  can  be  estimated  that  from 
about  20  to  25  per  cent,  of  women  complaining  of  digestive  disturb- 
ances are  affected  with  movable  kidney  and  enteroptosis.  Unques- 
tionably the  percentage  of  gastroptosis  among  all  women,  including 
those  who  complain  of  no  symptoms,  will  average  at  least  15  per  cent, 
in  our  city  population.  The  advocates  of  nephropexy  find  nephrop- 
tosis, disregarding  the  other  ptoses,  in  20  to  33  per  cent,  of  all  women, 
a  satisfactory  surgical  viewpoint. 

The  improvement  following  promiscuous  nephropexy  in  gastro- 
intestinal and  other  symptoms  can  be  often  imputed  to  the  post- 
operative rest  in  bed  and  to  the  increase  in  fat  by  proper 
feeding. 

The  ratio  of  males  complaining  of  digestive  disturbances,  with 
enteroptosis  and  nephroptosis,  is  about  2  to  3  per  cent.  The  ratio 
in  women  is  8  or  10  to  i  male. 

Glenard  finds  a  lower  ratio,  70  women  to  30  men  in  100  cases. 

Age.— The  most  frequent  age  is  from  eighteen  to  forty,  though 
between  fifty  to  sixty  the  condition  appears  most  marked. 

Symptoms. — Gastroptosis  may  exist  without  the  production  of 
any  symptoms;  while,  on  the  other  hand,  it  may  be  present  with 
those  of  a  mild  character,  or  may  finally  present  the  aggravated 
type  of  Glenard.  The  following  symptoms  in  part  or  whole  may  be 
present:  Some  cases  complain  chiefly  of  nervous,  cardiac,  gastro- 
intestinal or  pelvic  disturbances,  or  of  special  organs,  such  as  the 
kidney  or  liver. 

There  is  usually  anemia,  a  feeling  of  weakness  or  faintness,  and 
fatigue  on  slight  exertion  and  backache.  The  appetite  in  some  cases 
is  poor,  while  in  others  quite  good. 


GASTROPTOSIS — ENTEROPTOSIS — GLENARD's    DISEASE  347 

Some  patients  have  the  symptoms-complex  of  hyperchlorhydria, 
while  others  complain  of  belching  and  discomfort  immediately  after 
eating.  There  is  usually  marked  and  obstinate  constipation,  rarely 
diarrhea;  at  times  intestinal  catarrh  or  mucous  colic.  Flatulence  is 
present.  They  have  headache,  are  frequently  nervous  and  hysteric, 
and  at  times  neurasthenic.  There  is  often  a  feeling  of  weight  or 
bearing  down  in  the  abdomen,  which  is  relieved  by  proper  support. 
Menstrual  disorders  are  frequently  present,  dysmenorrhea  quite 
often.  At  times  the  pain  and  discomfort  are  focused  in  the  kidneys, 
especially  the  right ;  and  in  addition  .  they  may  have  attacks  of 
Dietl's  crisis.  Pains  in  the  region  of  the  liver  and  gall-bladder 
occur  in  some,  and  there  may  be  attacks  of  pain  resembling  gall- 
stones and  occasional  jaundice.  There  may  be  irritability  of  the 
bladder,  with  frequent  inclination  to  urinate,  and  pains  in  the  ovaries 
and  appendical  region.  Various  sensitive  points  are  often  found  in 
other  regions  of  the  abdomen.  Palpitation  is  frequently  present 
and  occasionally  attacks  of  tachycardia  may  occur. 

Physical  Examination. — Inspection. — ^These  patients  are  usually 
thin  and  slender;  the  abdominal  walls  are  generally  flaccid.     There 


Fig.    153. — Abdominal    projection;    lead-tape  outline  between  anterior  su- 
perior  spines;  curved  line,   when  standing;  fiat  line,  when  lying  on  back  (from 


Gallant) . 

is  a  concavity  between  the  costal  arches  in  the  epigastrium  from  the 
ensiform  to  the  umbilicus;  and  in  some  a  vertical  median  sulcus 
between  the  recti  muscles  wider  above  than  below. 

In  the  dorsal  position  the  abdomen  may  be  flattened  below  and 
bulge  laterally;  and  when  the  patient  is  erect  the  epigastrium 
becomes  more  depressed;  while  the  hypogastric  regions  from  the 
umbilicus  to  the  symphysis  and  the  pubic  region  markedly  bulge 
forward  and  outward  (pot  belly).     Fig.  153  shows  this  clearly. 

Palpation. — Diastasis  (separation  of  the  recti  muscles)  can  be 
readily  appreciated.  Stiller's  floating  tenth  rib  is  present  in  some 
cases.  Marked  pulsation  of  the  abdominal  aorta  is  often  met  with, 
as  it  is  uncovered  by  the  stomach.  Movable  kidney  of  varying 
degrees  can  be  readily  appreciated,  and  this,  taken  in  connection 
with  the  splashing  sound  found  below  the  normal  position  of  the 
lower  border  of  "the  stomach,  is  pathognomonic  of  gastroptosis. 
The  corde  colique  transverse  is  generally  found  to  be  the  pancreas, 
which  may  also  prolapse. 

Splashing  Sound. — This  is  the  best  method  to  determine  the 
lower  border  of  the  stomach  and  has  been  thoroughly  described. 


348  DISEASES    OE   THE    STOMACH   AND   INTESTINES 

If  no  splash  can  be  originally  detected,  create  it  artificially  by 
giving  water,  or  if  required,  add  a  little  Vichy,  or  tartaric  acid  and 
sodium  bicarbonate. 

Inflation  of  the  stomach  with  air  or  CO2  will  settle  doubtful 
cases,  as  the  upper  border  is  then  to  be  seen  on  inspection,  and 
percussion  is  an  aid. 

Gastrodiaphany  is  an  accurate  method. 

Percussion. — ^There  is  at  times  dulness  or  flatness  in  the  epigas- 
trium when  the  stomach  is  markedly  depressed,  the  liver  descending 
in  such  cases.  It  is  difficult  to  differentiate  by  simple  percussion 
unless  CO2  distention  has  also  been  employed.  The  scratch  method 
is  of  assistance. 

Gastric  Secretion. — Examination  of  the  Gastric  Contents. — 
Ewald's  test  breakfast  should  be  employed .  and  gastric  analysis 
made  in  every  case.  Hyperchlorhydria,  hypochlorhydria,  or,  more 
rarely,  achylia  gastrica  (functional)  may  be  present.  Rarely  the  secre- 
tion is  normal,  and  then  usually  in  the  cases  found  accidentally,  pre- 
senting no  symptoms. 

I  agree  with  George  R.  Lockwood  to  this  extent,  that  in  many 
cases  no  evidences  of  fermentation  can  be  found  on  test,  and  the  gas 
also  may  be  odorless.  In  hysteric  women  some  of  the  air  is  swallowed. 
On  the  other  hand,  in  some  patients  with  associated  marked  dilatation 
(the  latter  probably  being  primary),  such  as  I  have  seen  among  the 
nervous  and  insane  at  the  Manhattan  State  Hospital,  marked  fer- 
mentation has  been  found. 

The  treatment  is  modified  by  the  gastric  findings.  It  is  evident, 
in  some  cases,  that  the  secretory  conditions  are  influenced  by  the 
misplacement,  since  Graham-Rogers,  at  the  Ward's  Island  Clinic, 
found  that  in  4  out  of  7  cases  (6  of  hyperchlorhydria  and  i  of  hypo- 
chlorhydria) improvement  followed  the  use  of  Rose's  belt^  alone, 
without  medication  or  special  diet. 

Motor  Functions. — Motor  insufficiency-  is  undoubtedly  present 
in  some  cases.  On  the  other  hand,  many  cases  exist  with  few  or  any 
gastric  symptoms,  and  though  there  is  relaxation  of  the  musculature 
of  the  stomach,  compensation  takes  place  probably  by  relaxation 
of  the  pyloric  ring,  so  that  the  contents  of  the  stomach  enter  the 
intestine  within  the  normal  limit  of  time.  Per  contra  on  some  occa- 
sions, or  from  some  cause,  this  compensation  may  fail  and  then  symp- 
toms develop.  Motor  functions  appear  only  slightly  diminished  in 
other  cases,  or  even  normal,  as  just  explained. 

This  is  the  probable  explanation  for  those  cases  which  have 
existed  for  years  without  symptoms  and  in  whom  they  suddenly 
develop. 

Stomach  and  Small  Intestine. — Gastroptosis  may  occur  in 
various  forms  and  degrees,  semi-oblique  of  different  degrees,  looped, 

1  Rose  and  Kemp,  Atonia  Gastrica,  p.  124. 

2  Ibid.,  p.  79. 


GASTROPTOSIS — ENTEROPTOSIS — GLENARD's   DISEASE 


349 


or,  more  rarely,  crescentic,  and  even  the  vertical  stomach  (Figs. 
154-158).  In  some  cases  we  may  have  primary  dilatation  and  then 
ptosis.  These  illustrations  represent  gastrodiaphany  of  various 
cases. 

As  far  as  I  can  determine,  from  physical  examination,  post- 
mortem, and  operative  cases,  especially  in  the  marked  semi-oblique 
or  in  the  vertical  stomach,  there  seems  to  be  a  straightening  of  the 
pyloric  curve  and  some  dilatation  of  the  pyloric  end  and  of  the  duo-, 
denum,  probably  with  relaxation  of  the  pylorus.  The  supports  of 
the  duodenum  are  relaxed  and  it  crosses  the  spine  at  a  lower  level. 
I  believe  there  is  some  relaxation  with  descent  of  the  pancreas,  and 


Fig.  154. — Slight  gastroptosis. 


Fig.  155. — Gastroptosis. 


also  relaxation  of  the  mesentery  and  descent  of  the  rest  of  the  small 
intestine. 

The  duodenal  distention  is  to  be  expected  from  gravitation  of 
the  stomach  contents,  and  as  there  is  relaxation  of  the  mesentery 
I  am  skeptical  of  the  so-called  ''chronic  mesenteric  traction"  with 
dilatation  as  a  result. 

Gastroptosis  should  favor  acute  dilatation  of  the  stomach,  on  the 
mesenteric  traction  theor}^,  but  I  have  never  seen  such  a  condition 
associated  with  acute  ectasy. 

Large  Intestine. — Enteroptosis. — Descent  of  the  transverse  colon 
is  most  common  (Fig.  159),  as  can  be  demonstrated  by  inflation  with 
air  or  water,  or  with  bismuth  and  x-rays ;  but  undoubtedly  there  may 


350 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


Fig.  156. — Vertical  stomach. 


Fig.  157. — Vertical  stomach  (extreme). 


be  relaxation,  with  changes  in  the  position  of  the  sigmoid  or  even  of 
the  descending  colon.     I  have  seen  a  case  of  this  type  recently. 


Fig.  158. — Crescentic  form  of 
gastroptosis. 


Fig.  159. — Enteroptosis. 


Nephroptosis. — It  seems  important  to  further  discuss  this  con- 
dition, though  I  have  already  described  many  of  its  features.     Mov- 


GASTROPTOSIS — ENTEROPTOSIS — GLENARD'S   DISEASE  35 1 

able  kidney  from  traumatism  or  straining  and  the  congenital  floating 
kidney  with  a  long  mesonephron  constitute,  I  believe,  a  comparatively 
small  percentage  of  all  cases — in  my  own  opinion,  about  5  per  cent. ; 
while  jMeynert  places  them  at  10  per  cent.  The  balance  are  con- 
comitants of  enteroptosis  (gastroptosis).  It  is  most  common  on  the 
right  side. 

Einhorn,  as  well  as  many  other  authors,  recognize  movable 
kidney  as  an  essential  symptom  of  enteroptosis. 

Nephroptosis  occurs  at  least  six  or  seven  times  more  frequently 
in  women  than  in  men. 

Nephroptosis  exists  in  about  15  per  cent,  of  all  women  examined, 
associated  with  gastroptosis;  but  in  many  cases  no  symptoms  are 
present.  No  worse  judgment  can  be  shown  than  to  tell  a  patient 
that  she  has  a  movable  kidney. 

Edebohls  finds  it  in  20  per  cent,  of  his  cases,  disregarding  asso- 
ciated ptoses,  and  some  even  place  it  at  33  per  cent. 

The  normal  kidney  is  slightly  movable  during  respiratory  move- 
ments. The  most  accurate  method  of  kidney  palpation  I  have 
already  described. 

Glenard  classifies  four  degrees  of  movable  kidney: 

First  Degree. — The  lower  pole  of  the  kidney  is  palpable  on  deep 
inspiration  and  slips  back  on  expiration.     It  cannot  be  arrested. 

Second  Degree. — The  body  of  the  kidney  can  be  palpated  and 
arrested,  but  not  the  upper  border. 

Third  Degree. — ^The  superior  border  of  the  kidney  can  be  palpated. 

Fourth  Degree. — The  entire  kidney  is  palpable  and  it  may  be 
found  in  various  regions  of  the  abdomen,  near  the  gall-bladder  or  as 
low  as  the  appendical  region. 

I  have  already  referred  to  the  various  symptoms  attributed  to 
movable  kidney,  such  as  dilatation  of  the  stomach  due  to  pressure 
on  the  duodenum ;  jaundice ;  gall-stone  symptoms,  or  stasis  with  the 
production  of  stone;  gastro-intestinal  and  pelvic  disturbances; 
chronic  appendicitis  as  a  result  of  congestion  from  compression  of 
the  superior  mesenteric  vein  against  the  pancreas  and  spine  (in  20 
per  cent,  of  cases,  according  to  Edebohls). 

All  these  symptoms  are  referable  to  splanchnoptosis. 

Goelet  believes  that  in  75  per  cent,  of  nephroptosis  of  the  third 
degree,  or  beyond,  there  is  a  pyelonephritis  or  interstitial  nephritis. 

In  20  cases  of  nephroptosis  of  the  third  degree  or  more  (with 
enteroptosis)  at  the  Manhattan  State  Hospital,  I  requested  LeRoy 
Broun  to  examine  the  gynecologic  conditions,  and  in  no  case  could 
any  connection  be  found  between  the  prolapsed  kidney  and  the 
genital  organs.  Ferd  C.  Valentine'  and  Terry  M.  Townsend,  as  a 
check,  made  special  examinations  of  the  genito-urinary  tract  and 
urine,  but  found  no  evidence  of  nephritis  or  pyelonephritis  in  these 
20  cases. 

'  Kemp,  American  Journal  of  Urology,  January,  1906. 


352  DISEASES   OF   THE    STOMACH   AND    INTESTINES 

Such  examinations  should  not  be  made  immediately  after  palpa- 
tion, as  Menge  demonstrated  that  albuminuria  appeared  directly 
thereafter. 

Schreiber^  showed  this  in  39  out  of  42  cases  examined  within  ten 
to  fifteen  minutes  after  palpation,  and  that  it  sometimes  lasted  hours. 
Renal  epithelium,  red  and  white  cells,  but  no  casts  were  found. 
He  believes  it  will  furnish  a  method  of  differential  diagnosis,  as  if,  on 
palpation  of  a  doubtful  mass,  this  condition  occurs,  it  will  prove  to  be 
kidney.  Of  course,  nephritis  or  pyelonephritis  may  occur  in  some 
cases;  and  after  differential  ureteral  catherization,  if  both  kidneys  are 
prolapsed,  nephropexy  is  indicated  in  the  diseased  prolapsed  organ. 

Hydronephrosis,  or  adhesion  of  the  kidney  to  the  appendix  or 
gall-bladder,  may  also  occur  occasionally. 

In  some  cases  more  marked  or  severe  symptoms  may  be  attributed 
to  the  movable  kidney: 

(i)  There  may  be  a  weight  or  special  feeling  of  traction  on  that 
side,  increased  on  standing  or  walking,  and  lessened  in  the  recumbent 
posture. 

(2)  The  kidney  may  be  increased  in  size,  tender  on  pressure,  and 
there  may  be  pain  and  tenderness  in  the  lumbar  region,  frequent 
urination,  and  burning  headache. 

(3)  Dietl's  crisis,  probably  due  to  torsion  of  the  pedicle,  will 
produce  severe  abdominal  pain,  chills,  nausea,  vomiting,  fever,  and 
even  collapse.  The  urine  may  be  high  colored  and  blood  be  present. 
Abdominal  support  should  first  be  tried  systematically  in  these 
conditions  before  operation  is  advocated. 

Floating  Liver  (Movable  Liver). — Osier  claims  that  in  a 
considerable  number  of  cases  there  is  a  m-istaken  diagnosis.  One 
anomaly  is  the  tilting  forward  of  the  organ,  so  that  the  antero- 
posterior axis  becomes  vertical  and  not  horizontal,  and  a  consider- 
able part  of  the  surface  of  the  right  lobe  is  in  contact  with  the 
abdominal  wall. 

In  one  type  of  lacing  liver,  the  anterior  part  of  the  right  lobe  is 
greatly  prolonged,  a  shallow  transverse  groove  separating  it  from 
the  rest  of  the  organ. 

A  slight  grade  of  mobility  (floating  liver)  is  found  in  enteroptosis, 
but  the  cases  reported  are  comparatively  few. 

In  some  cases  the  upper  surface  may  lie  below  the  costal  margin. 
G.  E.  Graham  has  collected  70  cases.     The  condition  is  rare  in  men. 

In  some  cases  of  enteroptosis  with  hepatoptosis,  the  symptoms 
may  be  fairly  marked  in  the  liver,  there  being  pains  in  the  hepatic 
region  radiating  toward  the  back  and  at  times  of  a  tearing  character. 
There  may  be  some  local  tenderness  and  attacks  similar  to  hepatic 
colic,  though  usually  no  jaundice. 

Einhorn^  described   several  groups  of  cases,   dyspeptic  asthma 

1  Zeitschrift  fiir  klin.  Med.,  vol.  Iv,  No.  3. 

2  Medical  Record,  September  16,  1S94. 


GASTROPTOSIS — ENTEROPTOSIS — GLENARD'S   DISEASE  353 

among  them,  but  from  my  own  point  of  view  this  condition  seems 
to  be  a  part  and  parcel  of  the  general  syndrome  "enteroptosis," 
with  marked  local  symptoms,  such  as  pain  or  colic,  in  some  cases. 
In  extreme  cases  the  liver  may  drop  down  so  that  the  upper  surface 
is  below  the  costal  margin. 

Cardioptosis. — In  my  own  experience,  ptosis  of  the  heart  is 
present  only  in  marked  cases  of  splanchnoptosis,  especially  where 
there  is  skeletal  deformity.  Einhorn  finds  it  associated  wdth  float- 
ing liver.  The  latter  is  more  frequently  a  concomitant  of  skeletal 
deformity,  I  believe,  and  hence  the  two  conditions  are  associated. 
Movable  spleen  may  occur  from  below  the  rib  even  into  the  pelvis. 
There  may  be  dragging  pains  in  the  side,  torsion  of  the  pedicle,  swell- 
ing of  the  organ,  with  pain  and  fever  associated. 

Diagnosis. — Curiously  enough,  the  majority  of  wTiters  pay 
chief  attention  to  nephroptosis,  refer  to  the  stomach  as  dilated  (a 
result  of  kidney  pressure),  and  do  not  differentiate  between  gastrop- 
tosis  and  dilatation  of  the  stomach.  It  is  the  position  of  the  upper 
border  which  determines  ptosis,  but  the  following  symptoms  will 
usually  settle  the  diagnosis.  The  peculiar  conformation  of  the  abdo- 
men heretofore  described,  the  separation  of  the  recti,  movable  kid- 
ney, and  the  determination  that  the  lower  border  of  the  stomach  is 
abnormally  low,  are  sufficiently  diagnostic  of  gastroptosis. 

Inflation  or  gastrodiaphany  may  be  necessary  in  doubtful  cases 
to  settle  the  question. 

G16nard's  "Belt  Test." — If  one  stand  behind  the  patient  and, 
encircling  him  with  the  arms,  lift  up  and  support  the  lower  pro- 
tuberant abdomen,  and  this  gives  relief,  it  suggests  enteroptosis. 

Prognosis. — The  cases  of  congenital  type  with  funnel  thorax 
or  other  skeletal  deformities  are  the  most  unfavorable  to  treat;  but 
even  in  these  much  can  be  done. 

The  acquired  type  presents  a  favorable  prognosis  as  to  absolute 
cure,  though  some  tend  to  relapse  if  continuous  care,  as  to  regulation 
of  mode  of  life,  exercise,  and  diet  is  not  kept  up.  I  have  seen  a 
number  of  cures,  as  has  every  other  observ^er. 

Treatment. — Prophylaxis. — Much  can  be  done  to  prevent  the 
acquired  type  of  gastroptosis.  Improperly  made  corsets  compress 
the  thorax  or  waist.  Tight  lacing  and  the  use  of  tight  bands  around 
the  waist  are  productive  of  ptosis.     These  should  be  avoided. 

In  my  opinion,  most  of  the  Landau  (post-partum)  cases  of  splanch- 
noptosis are  absolutely  preventable,  the  fault  frequently  being  due 
to  the  physician  in  attendance,  the  patient's  abdomen  not  being 
properly  supported,  and  she  also  being  allowed  to  leave  the  bed  too 
soon.  There  is  a  marked  thinning  and  weakening  of  the  abdominal 
wall  during  pregnancy,  and  after  delivery  immediate  attention  should 
be  given  to  its  support. 

For  several  years  Douglas  H.  Stewart,  of  New  York,  has  been 
employing  as  a   routine   post-partum   method   of   support    (at   my 

23 


354 


DISEASES   OF  THE   STOMACH   AND   INTESTINES 


suggestion)  Rose's  plaster  strapping,  reinforcing  it  with  lateral 
soft-rubber  strips  (an  idea  of  his  own).  He  states  that  it  supports 
the  organs  perfectly,  prevents  abdominal  relaxation,  and  enables 
the  patient  to  sit  up  in  bed  earlier,  with  resulting  improved  drainage 
of   the   uterus,    and   to   be   about   at   an   earlier   period. 

Bassler^  treats  of  the  necessity  of  abdominal  support  after  confine- 
ment, and  describes  methods  of  strengthening  the  abdominal  muscles 
and  the  value  of  forced  feeding. 

Treatment  of  Existing  Gastroptosis  (Splanchnoptosis). — 
There  are  three  chief  principles  involved: 

(i)  The  support  and  strengthening  of  the  abdominal  muscles, 
which  also  increase  intra-abdominal  pressure. 

(2)  The  increase  of  intra-abdominal  pressure,  by  reducing  the 
volume  of  the  abdominal  cavity  through  accumulation  of  fat,  and 
thus  lifting  up  the  stomach. 

(3)  Correction  of  the  gastro-intestinal  disturbances  and  the  toning 
up  of  the  nervous  system. 


Fig.  160. — The  proper  way  of  adjusting  the  corset  (after  Gallant). 

(i)  Abdominal  Support. — The  selection  of  a  proper  apparatus- 
for  mechanical  support  to  the  abdominal  muscles,  which  at  the  same 
time  will  increase  intra-abdominal  tension,  is  the  first  indication. 

I  have  employed,  by  preference  for  some  time  past,  adhesive 
plaster  strapping  in  the  form  of  the  belt  devised  first  by  Achilles 
Rose.  I  have  already  referred  to  the  superiority  of  moleskin,  first 
suggested  in  this  country  by  me  after  numerous  experiments.  The 
Z.  O.  type  should  be  used  by  the  method  already  described.  The 
support  afforded  is  continuous,  should  never  be  kept  on  over  three 
to  five  weeks,  and  on  signs  of  loosening,  a  new  belt  should  be 
applied;  the  patient,  between  belts,  taking  a  full  bath  and  employ- 
ing talcum  powder  over  the  surface  during  the  twelve  to  twenty- 
four  hours'  intermission.  My  longest  case  wore  the  belt  fourteen 
months,  winter  and  summer,  it  being  reapplied  every  four  to  six 
weeks,  with  a  gain  of  44  pounds  and  perfect  cure. 

Some  of  the  other  types  of  adhesive  strapping  belts  may  be 

1  Prophylactic  Measures  Against  the  Development  of  Landau  Cases  of 
Visceroptosis,  Therapeutic  Gazette,  September  15,  1907. 


GASTROPTOSIS — ENTEROPTOSIS — GLENARD'S    DISEASE 


355 


employed  if  the  wide  plaster  necessary  for  Rose's  belt  cannot  be 
procured.  Pressure  is  exerted  by  the  belt,  from  the  symphysis  to 
the  umbilicus  in  front,  the  intestines  are  forced  up,  and  hence  the 
stomach;  and  the  increased  pressure  aids  in  holding  back  the 
kidneys. 

Next  in  value  to  adhesive  plaster  is  the  Gallant  corset,  which  also 
exercises  upward  pressure  and  support  below,  and  is  loose  above. 
The  method  of  its  application  is  shown  in  Fig.  i6o. 

The  La  Grecque  corset  (Von  Noorden's),  recently  devised,  is  an 
excellent  appliance.  It  well  supports  the  spine  and  pelvis,  is  made 
in  a  single  piece  behind,  and  is  subdivided  in  front,  as  in  Fig.  i6i,  A. 


Fig.   i6i. — La  Grecque  corset: 


A,  Lower   segment  of   corset;    B,  corset  after 
adjustment. 


In  Fig.  i6i,  B,'is  shown  the  corset  after  application.  It  should  be 
applied  in  the  dorsal  position,  like  the  Gallant  corset.  The  pressure 
is  exerted  like  Rose's  belt,  from  the  symphysis  to  the  umbilicus,  and 
it  is  loose  about  the  thorax  and  upper  abdomen.  Of  late  I  use  the 
adhesive  strapping  for  several  months  and  then  follow  it  with  this 
corset.     The  indications  are  the   same  as  for  Rose's  plaster. 

If  the  patient  will  not  consent  to  these  methods,  the  silk  abdominal 
bandages,  as  previously  illustrated,  are  useful.  In  male  cases  Rose's 
belt  and,  later,  the  silk  belt  are  indicated. 

Supports  formed  with  pads  for  special  organs  are  unscientific. 

Kilmer's  belt,  drawn  snug  below  and  lax  above,  or  the  Van 
Valzah-Hayes  belt  can  be  employed. 


356  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

Exercise. — Massage. — Gymnastics. — There  are  marked  inconsist- 
encies in  many  of  the  recommendations  as  to  active  exercise,  flexion, 
and  extension  of  the  body  by  elevation  of  the  legs,  gymnastics,  etc., 
to  strengthen  the  abdominal  muscles.  There  is  no  better  way  to 
take  off  abdominal  fat  and  to  reduce  omental  fat  than  by  these 
means ;  and  in  the  cases  with  marked  weight  reduction  it  is  impossible 
to  put  on  fat  if  excessive  exercises  are  employed. 

In  moderation  and  properly  directed,  they  are  of  service  later 
when  the  weight  has  been  increased.  Driving  or  moderate  walks  in 
some  cases  are  useful. 

Massage. — On  the  other  hand,  gentle  abdominal  massage  and 
often  general  massage  of  mild  type,  taken  several  times  a  week,  will 
improve  the  muscular  tone.  The  use  of  Hght  cannon-ball  massage  of 
the  abdomen,  taken  five  minutes  once  or  twice  a  day,  or  mild  vibra- 
tory massage,  at  home  in  bed,  with  the  Vedee  vibrator,  I  have  found 
of  service. 

In  the  severe  type  of  case,  absolute  rest  in  bed  for  three  to  six 
weeks  with  the  Rose's  belt  appHed,  forced  feeding,  and  mild  massage, 
etc.,  give  the  best  results;  and  if  the  patient  is  very  much  prostrated 
I  omit  massage  at  first. 

2.  Increase  of  Abdominal  Pressure  through  Diet  hy  Fat  Accumula- 
tion.— Diet. — There  are  certain  general  principles  we  must  follow: 

If  there  is  hyperchlorhydria,  plenty  of  albuminous  foods  and  fats 
and  diminished  starchy  foods  should  be  given;  frequent  feedings; 
avoidance  of  acids,  spices,  and  alcohol.     Often  alkahs  are  required. 

If  hypochlorhydria  or  achylia,  little  meat  and  abundance  of 
carbohydrates  and  fats,  with  dilute  hydrochloric  acid,  stomachics,  etc. 

Not  more  than  8  oz.  (250  cc.)  of  fluid  should  be  taken  at  a  time, 
and  thorough  mastication  of  the  food  should  be  enjoined.  If  the 
case  is  not  confined  to  bed,  a  rest  of  fifteen  to  thirty  minutes  after 
each  meal,  if  possible,  is  advisable.  The  patient  should  take  the 
three  chief  meals  daily  at — 

!r  10.^0  A.  M., 
U  -^O  P    M 
with  intermediate  feedings  at  A  -^'^^^  ^^^^^  ^^ 
[9.30  P.M. 

John  Russell's  method,  as  employed  in  tuberculosis,  is  of  value 
in  some  cases.  The  foods  especially  of  use  to  increase  weight  and 
which  can  be  employed  for  the  interval  feedings  are : 

Milk,  raw  eggs,  cream,  oj  (30  cc.)  in  milk,  Bviij  (250  cc.)  kumyss, 
matzoon,  bacillac,  lac  tone-buttermilk,  crackers  or  bread  with  plenty 
of  butter,  and  sanatogen  (preferably  flavored). 

Raw  eggs  can  be  given,  beaten  up  in  milk.  It  is  well  to  start 
with  I  or  2  daily,  and  increase  gradually  to  6  or  8  per  day.  They 
possess  considerable  value.  One  could  give,  for  example,  at  the 
intermediate  feedings: 


GASTROPTOSIS — EXTEROPTOSIS — GLENARD'S    DISEASE  357 

10.30  A.  M. — Milk,  oviij  (250  cc),  with  2  raw  eggs. 
3.30  p.  M. — Kumyss,  oviij  (250  cc). 
9.30  p.  M. — Same  as  at  3.30  p.  M.,  and  vary  the  methods. 

Two  soft-boiled  eggs  can  be  given  for  breakfast. 

Green  vegetables  and  raw  or  cooked  fruits  should  be  given  for 
constipation,  depending  on  the  gastric  conditions.  Strict  attention 
to  the  bowels  is  imperative. 

I  have  seen  the  stomach  elevated  3  or  4  inches  by  the  increase 
of  fat. 

Electricity. — In  the  ambulant  cases  the  use  of  static  electricity 
will  prove  of  service  with  some  patients  to  improve  the  general 
muscular  tone,  or  it  may  be  employed  after  the  rest  cure  has  been 
completed.  The  external  application  of  galvanic  or  faradic  elec- 
tricity I  have  used  with  good  results  in  some  cases,  but  never  remove 
the  belt. 

Intragastric  faradization  has  been  recommended  to  improve  the 
atony  of  the  stomach,  and  galvanization  for  the  pain.  I  have  had 
patients  bitterly  complain  of  the  intragastric  method;  one  case 
notably  had  been  treated  thus  systematically,  with  increasing 
nervous  symptoms  being  produced  and  marked  nausea,  stating  she 
was  worse  after  each  treatment.  The  simple  method  of  external 
application  seems  to  me  advisable  in  those  cases. 

Massage  of  the  Kidney. — Several  methods  have  been  recommended 
for  treatment  of  the  painful  movable  kidney: 

The  operator,  sitting  on  the  side  of  the  kidney  to  be  massaged, 
places  the  left  hand  (if  it  is  the  right  kidney)  on  the  lumbar  region, 
so  that  the  organ  rests  on  the  finger,  the  thumb  being  supported 
by  the  ribs.  With  the  finger-tips  of  the  right  hand  he  pushes  on 
the  kidney  from  in  front  and  gently  kneads  it. 

Brandt  places  the  patient  in  the  lithotomy  position,  and  having 
replaced  the  kidney,  places  both  hands  in  front  under  the  margin  of 
the  ribs,  and  makes  vibratory  movements  backward  and  upward, 
allowing  the  finger-tips  to  slip  around  to  the  back.  The  patient  aids 
in  securing  this  position  by  lifting  his  buttocks. 

-  As  palpation  alone  will  cause  albuminuria,  I  do  not  approve  of 
these  methods,  hut  merely  refer  to  them.  It  is  sufficient  to  replace  the 
kidney. 

Elevation  of  the  Eoot  of  the  Bed. — This  method  may  be  employed 
in  those  cases  taking  the  rest  cure  who  do  not  wear  an  abdominal 
support  continuously.  Elevation  of  the  buttocks  may  be  sub- 
stituted.    They  are  unnecessary  when  Rose's  belt  is  employed. 

Iron  and  arsenic  are  indicated  in  all  cases,  such  as — 

Iron  tropon,  5j  (40).  t.  i.  d.;  or 
Peptomangan  (Gude),  oj  to  ij  (4.0-2.0);  with 
Fowler's  solution  of  arsenic,  Tn.3  to  5  (0.177-0.296  cc),  t.  1.  d, 
or  any  good  combination  of  iron  and  arsenic. 

An  excellent  pill  is  Blaud's  iron,  gr.  5  (0.3),  in  which  sodium 
arsenate,  gr.  -g-^g  to  ^'o  (0.00108-0.002 1),  has  been  incorporated. 


358  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

If  no  hyperchlorhydria  is  present,  strychnin,  gr.  q^^  to  3^0  (0.00108- 
0.0021),  can  be  included. 

Hyperacidity  should  be  treated  with  the  alkalis. 

Hypo-acidity  with  nux,  strychnin,  hydrochloric  acid,  and 
stomachics. 

Bromid,  gr.  10  (0.6),  or  veronal,  gr.  5  to  yh  (0.33-0.5),  sulfonal, 
gr.  10  (0.6),  or  trional,  gr.  10  (0.6),  are  valuable  for  sleeplessness, 
given  an  hour  before  retiring. 

Hydrotherapy.— The  Scotch  douche,  one  to  two  minutes  over  the 
abdomen,  in  convalescent  cases  has  rendered  service. 

The  Priessnitz  compress  aids  to  relieve  pain. 

A  glass  of  cold  water,  Vichy  or  Carlsbad,  on  rising  helps  the  bowel 
action. 

Dietl's  Crisis. — Apply  heat  to  the  kidney ;  employ  fluid  diet ;  ele- 
vate the  foot  of  the  bed ;  replace  the  kidney. 

Codein,  gr.  i  to  ^  (0.016-0.022),  or  morphin,  gr.  |  to  |  (0.008- 
0.016),  may  be  required,  by  hypodermic. 

Constipation. — Olive  oil  enemata;  cascara;  comp.  rhubarb,  if 
required,  are  excellent. 

Complications,^  such  as  mucous  colic  or  catarrhal  colitis,  must  be 
appropriately  treated. 

Surgery. — In  splanchnoptosis,  if  all  medical  treatment  after  a 
year  conscientiously  applied  prove  a  failure,  suture  of  the  recti  (ab- 
dominis) and  thus  tightening  the  abdomen,  as  advocated  by  Robert 
T.  Morris  and  by  Charles  Codman,"  is  the  most  scientific  procedure. 

If  there  is  nephritis,  pyelonephritis,  or  intermittent  hydronephro- 
sis confined  to  the  prolapsed  kidney,  then  nephropexy  is  indicated. 
After  repeated  attacks  of  Dietl's  crisis,  when  medical  measures  afford 
no  relief,  nephropexy  may  be  advised. 

Hydronephrosis  or  pyelonephritis  may  be  of  such  a  character 
as  to  require  nephrectomy. 

Operations  on  individual  organs  I  am  opposed  to  unless  there  be 
marked  gastric  dilatation  with  the  ptosis. 

Gastroplication,  shortening  of  the  lesser  omentum,  attaching 
the  lesser  curve  of  the  stomach  to  the  abdominal  wall,  suture  of  the 
transverse  colon  to  the  abdominal  wall,  sewing  the  greater  omentum 
to  the  abdominal  wall,  have  all  been  recommended. 

Gastro-enterostomy  may  be  indicated  in  gastroptosis  with  ectasia 
and  marked  fermentation,  which  does  not  respond  to  medical  treat- 
ment.    The  spleen  has  been  stitched  up  or  rernoved  if  inflamed. 

Duodeno- enter  ostomy  has  been  advocated  by  Byron  Robinson, 
but  I  see  no  indication  for  it. 

Elliot^  recommends  anchoring  the  liver  in  hepatoptosis. 

In  rare  cases,  gastroplication,  with  shortening  of  the  lesser 
omentum ;  or  the  latter  with  gastro-enterostomy  might  be  necessary. 

^  See  under  Constipation  for  other  remedies. 

2  Medical  Record,  October  19,  1907.        ^  Medical  News,  November  12,  1904. 


CHAPTER  XVII 

NERVOUS  AFFECTIONS  OF  THE  STOMACH 

Gastric  neuroses  may  be  defined  as  functional  disturbances  of 
the  stomach  without  any  discoverable  anatomic  basis,  there  being 
no  organic  lesion  of  the  organ. 

Etiology. — These  cases  have  either  inherited  a  nervous  con- 
stitution or,  through  indiscretions,  have  brought  about  a  condition  of 
nervous  prostration.  Sometimes  the  gastric  disturbances  have 
apparently  a  reflex  origin,  depending  on  disturbances  in  remote  parts 
of  the  body,  as  in  the  sexual  organs,  appendix,  eyes,  etc.,  and  these 
factors  must  always  be  searched  for. 

They  are  divided  into  sensory,  motor,  and  secretory  neuroses, 
and  may  appear  separately  or  in  combination.  They  occur  most 
frequently  in  women  from  puberty  to  menopause,  and  quite  fre- 
quently at  these  special  periods.  In  men  they  appear  most  often 
during  middle  life  and  most  frequently  in  the  higher  classes.  There 
is  probably  a  predisposition  to  the  condition.  Worry,  extreme 
mental  exertion,  excesses,  and  excitement  may  be  predisposing 
factors.     Organic  lesions  of  the  stomach  must  be  excluded. 

Classification. — Neurosis  of  the  stomach  may  present  the 
appearance  of  some  primary  disease,  or  may  be  one  of  the  symptoms 
of  hysteria  or  neurasthenia,  or  may  be  a  reflex  symptom  due  to  dis- 
ease of  some  other  organ.  In  cases  of  this  last  description,  though 
there  is  no  organic  change  in  the  stomach  and  the  disturbance  in 
this  organ  is  purely  reflex,  there  is  an  anatomic  cause  elsewhere. 
They  should,  strictly  speaking,  be  differentiated  from  the  pure  gas- 
tric neuroses,  since  treatment  of  a  distant  diseased  organ  may  cure 
an  apparently  pure  gastric  neurosis.  This  emphasizes  the  necessity 
of  thorough  examination. 

-  Peculiarities. — Generally  the  nervous  system  shows  more  or 
less  deviation  from  normal  conditions.  Leube  and  Boas  have 
probably  best  described  the  condition.  There  are  headache,  mental 
depression,  lack  of  energy;  at  times  fear,  palpitation,  dyspnea,  and 
sweating.  On  the  other  hand,  there  may  be  excitement  and  sensi- 
tiveness. There  are  an  increase  or  diminution  of  reflexes,  local  hyper- 
esthesia, paresthesia,  or  anesthesia.  Polyuria  may  or  may  not  be 
present.  Some  patients  remain  in  comparatively  good  condition, 
while  others  emaciate. 

The  digestive  disturbances  are  usually  independent  of  the  quantity 
and  character  of  the  food,  and  are  not  always  connected  with  the  act 
of  digestion.     Errors  in  diet  are  often  not  followed  by  an  exacerbation 

359 


360  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

of  the  symptoms,  and  sometimes  they  occur  when  the  simplest  food 
has  been  taken. 

The  gastric  secretion  and  motor  functions  are  often  variable. 
We  may  find  hyperchlorhydria  at  one  time  and  normal  secretion 
at  another,  or,  conversely,  normal  conditions  may  alternate  with 
hypo-acidity  or  anacidity.  At  times  the  motor  functions  may  be 
normal,  at  others,  diminished. 

The  condition  of  the  bowxls  also  varies ;  there  may  be  constipa- 
tion alternating  with  diarrhea;  or  the  bowels  may  be  regular  and  a 
sudden  diarrhea  appear. 

Climate  and  surroundings  may  influence  the  condition. 

SENSORY  NEUROSES  OF  THE  STOMACH 

There  may  be  abnormal  sensations  more  or  less  general  in  char- 
acter external  to  the  stomach,  such  as  regarding  hunger,  appetite,  or 
abnormal  sensations  within  the  stomach  itself. 

Among  the  abnormal  sensations  of  appetite  are  bulimia  (or 
canine  hunger) ;  parorexia  (perversion  of  appetite) ;  polyphagia 
(excessive  eating) ;  akoria  (absence  of  satiation) ;  anorexia  (loss  of 
appetite). 

Bulimia 

Bulimia,  hyperorexia,  or  canine  hunger  (cynorexia)  denotes  a 
marked  increase  of  the  sensation  of  hunger  which  may  occur  in 
attacks,  either  as  an  independent  neurosis  or  as  a  secondarv  affection, 
the  result  of  some  other  disease.  The  attacks  are  paroxysmal. 
The  hunger  center  is  believed  to  be  located  in  the  medulla.  This 
center  is  probably  irritated  when  a  certain  degree  of  impoverishment  of 
the  blood  takes  place.  On  the  other  hand,  if  the  latter  is  marked, 
the  sensation  of  hunger  may  not  be  produced  or  may  even  be  sup- 
pressed. The  stomach  is  also  concerned  in  its  production,  and  the 
amount  of  food  contained  therein  has  an  influence.  For  example, 
with  hyperacidity  and  increased  motor  function,  hunger  is  present. 
In  a  case  of  mine  suffering  from  stenosis  of  the  pylorus  and  dilatation 
of  the  stomach,  while  before  operation  anorexia  was  marked,  the 
patient  is  now  continuously  hungry.  Reflexly,  the  hunger  center  is 
often  disturbed ;  this  loss  of  appetite  may  occur  after  fright  or  on  the 
appearance  of  food  that  is  greasy  and  badly  served,  whereas  with 
food  daintily  prepared  and  of  pleasant  odor,  the  appetite  is  increased. 
The  time  at  which  hunger  appears  depends  on  the  time  the  person  is 
accustomed  to  eat. 

Pathologically  the  sensation  of  hunger  may  also  be  stimulated 
or  inhibited  in  various  ways. 

Etiology. — Bulimia  may  be  a  primary  affection  or  may  be  second- 
ary to  ulcer  of  the  stomach,  hyperchlorhydria,  hypersecretion, 
epilepsy,  hysteria,  neurasthenia,  tumor  of  the  brain,  tapeworm, 
intestinal  diseases,  rarely  to  diseases  of  the  pancreas  or  to  diabetes 
mellitus. 


NERVOUS    AFFECTIONS    OF    THE    STOMACH  361 

Occurrence. — It  is  more  frequent  in  women  than  in  men  and 
most  frequent  from  eighteen  years  of  age  to  menopause. 

Symptoms. — The  patient  may  be  in  perfect  health,  when  suddenly 
a  feeling  of  intense  hunger  comes  on  which  is  extremely  persistent 
and  calls  for  food.  There  is  frequently  a  gnawing  in  the  stomach 
and  a  feeling  of  fear  and  anxiety.  Unless  the  hunger  is  relieved, 
headache,  trembling,  and  even  fainting  spells  may  occur.  The 
attack  may  take  place  immediately  after  a  large  meal  or  come  on  in 
the  night.  In  some  cases  small  amounts  of  food  will  relieve  the 
conditions;  in  others,  enormous  quantities  are  necessary.  One 
patient  recorded  ate  23  eggs  in  forty-five  minutes  and  drank  i| 
quarts  of  milk  and  i  quart  of  wine. 

Character  of  Attacks. — They  may  be  severe  or  very  sHght.  In 
some  cases  they  occur  every  few  hours ;  in  others  they  last  a  few  days, 
or  they  may  exist  chronically  and  last  for  years.  The  periodic  form 
is  generally  more  intense.     Hypermotility  is  found  in  some  cases. 

Prognosis. — In  the  secondary  form  it  depends  on  the  primary 
disease,  though  sometimes  bulimia  persists.  The  more  frequent 
and  violent  the  attacks,  the  worse  the  prognosis.  Ordinarily  it  is 
difficult  to  give  an  absolute  prognosis.  Gastritis,  atony,  or  dilatation 
may  result  in  some  cases. 

Treatment. — If  bulimia  is  secondary,  the  primary  disease  should 
be  treated,  such  as  hyperchlorhydria,  tapeworm,  diabetes,  or  neuras- 
thenic or  hysteric  symptoms.  For  the  bulimia  we  should  give 
frequent  light  meals  every  two  hours.  The  bromid  of  sodium, 
potassium,  ammonium,  or  strontium  may  be  given  in  gr.  xx  to  oss 
(1.3-2.0)  doses  two  or  three  times  daily;  for  example: 

P'.     Sod.  bromid oiiss  (lo.o) 

Aq.  menth.  piperit q.  s.  oiv  (125  cc). — M. 

Sig. — Two  teaspoonfuls  in  water  t.  i.  d.  after  meals. 

Codein,  opium,  and  cocain  I  strongly  deprecate,  though  recom- 
mended by  some.     There  is  great  danger  of  acquiring  the  habit. 

Tr.  belladonna,  tTlx  (0.59  cc.)  t.  i.  d.,  is  a  good  substitute. 

Arsenic  (Fowler's  solution),  TTLv  (0.296  cc),  or  sodium  arsenate, 
gr.  -5V  to  2V  (0.0013-0.0026),  or  arsenous  acid,  gr.  y^o  (0.00065) 
t.  i.  d.,  are  useful. 

Iron  can  be  given,  also  strychnin,  gr.  gV  (0.00108),  for  the  nerves. 

Change  of  climate  is  of  value.  Food  should  be  carried  by  those 
suffering  from  abnormal  hunger  for  immediate  use. 

Parorexia  (Perversion  of  Appetite) 

Sometimes  the  appetite  is  manifested  for  special  or  peculiar 
kinds  of  food.     There  are  three  types: 

(i)  Malacia,  a  desire  for  spiced  foods,  such  as  for  mustard, 
vinegar,  green  fruits,  etc. 


362  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

(2)  Pied,  a  desire  for  substances  that  are  not  foods,  such  as  earth, 
chalk,  ashes,  sand,  insects,  etc. 

(3)  Allotriophagia,  a  craving  for  disgusting  and  harmful  sub- 
stances, such  as  fecal  matter,  pins,  etc. 

Malacia  is  met  with  in  disturbances  of  the  stomach  and  neuras- 
thenia, while  the  other  types  occur  chiefly  in  idiots,  lunatics,  or 
severe  hysteria.  The  treatment  is  of  the  disease  which  is  the  cause 
of  the  perversion. 

Polyphagia 

Polyphagia  is  the  demand  for  large  quantities  of  food  before 
satiation  occurs.  The  cases  do  not  feel  hungry  until  the  food  is 
digested.  It  may  occur  as  a  primary  condition  in  neurotics,  or 
secondary  to  diseases  of  the  gall-bladder,  spleen,  diabetes,  or  brain 
tumor.  The  attacks  may  be  of  short  duration  or  as  a  chronic 
trouble.  One  case  could  eat  100  pounds  of  meat  in  twenty-four 
hours. 

Disease,  if  present,  should  be  treated;  neurotic  conditions  should 
be  corrected.     The  general  treatment  is  the  same  as  of  bulimia. 

Akoria 

Akoria  is  absence  of  satiety.  Patients  with  akoria  never  feel 
satiated,  and  never  know  when  to  stop  eating.  It  is  at  times  com- 
bined with  polyphagia.  It  is  met  with  among  the  neurasthenic  and 
hysteric.  Bromids  are  of  service  and  the  general  treatment  of  the 
nervous  condition. 

Nervous  Anorexia  (Anorexia  Nervosa) 

Anorexia  is  diminution  or  loss  of  appetite,  with  absence  of  the 
hunger  sense,  so  that  even  aversion  to  food  may  be  present. 

It  occurs  in  most  of  the  organic  as  well  as  in  the  functional  dis- 
orders of  the  stomach,  but  the  nervous  type  appears  as  a  primary 
affection. 

It  has  been  attributed  to  a  depressed  condition  of  the  hunger 
center  or  to  hyperesthesia  of  the  mucous  membrane  of  the  stomach. 

Etiology. — Psychic  shock,  some  mental  depression,  worry,  a 
disagreeable  odor,  or  some  nauseating  sight  may  cause  transitory 
anorexia  in  a  healthy  person. 

It  may,  however,  be  more  persistent  in  hysteria,  neurasthenia, 
and  the  psychoses;  morphin  and  excessive  smoking  may  produce  it. 
It  is  more  frequent  in  women  and  may  result  from  anemia  or  chlorosis. 

Symptoms. — There  is  at  first  loss  of  appetite,  and  the  patient 
begins  to  eat  less.  These  cases  may  first  have  ah  aversion  to  meat, 
and  later  to  bread  and  butter,  vegetables  and  all  solid  food,  and  may 
finally  live  only  on  fluids,  sometimes  on  very  small  quantities.  They 
often  vomit  at  the  sight  or  smell  of  food  and  may,  in  severe  cases, 
emaciate  markedly.     They  will  refuse  to  increase  their  nourishment 


NERVOUS    AFI^ECTIONS    OI^    THE    STOMACH  363 

("siturgy").  The  pulse  becomes  slow  and  the  temperature  sub- 
normal; they  become  pale,  cyanotic,  and  the  eyes  sunken.  Such 
cases  may  even  terminate  fatally.  This  condition  may  be  mistaken 
for  organic  disease  or  for  phthisis,  and  a  careful  physical  examination 
and  gastric  analysis  should  be  made. 

Treatment. — The  patient  should  be  impressed  with  the  idea 
that  he  must  take  his  food  in  sufficient  quantity  and  eat  everything 
put  before  him.     He  should  not  be  questioned  as  to  his  desires. 

Frequent  small  meals  with  kumyss,  matzoon,  bacillac,  lactone- 
buttermilk,  butter,  milk,  and  cream  should  be  given  to  improve 
nutrition.  Raw  eggs  are  of  service;  also  sanatogen  up  to  Bj  (32.0) 
daily  in  divided  doses. 

The  sour-milk  products  are  of  value,  as  auto-intoxication  is  an 
important  feature  in  these  neurasthenics. 

Stomachics,  such  as  tincture  of  nux  vomica,  TTLx  (0.59  cc.)  t.  i.  d., 
and  fluidextract  of  condurango,  lUxx  (1.184  cc),  are  of  service. 
Fluidextract  of  Peruvian  bark,  oj  (4.0)  t.  i.  d.,  is  excellent. 

I^.     Tr.  nucis  vomicae       \  .-    ^..  ,„    . 

Acid  hydrochlor.  dil.  / ^^   ^^J  "^^^^ 

Comp.  tinct.  cinchona oss  (16.0) 

Aq.  destU q.  s.  5iv  (125.0). — M. 

Sig. — oj  to  ij  (4.0-8.0)  t.  i.  d.  in  water  before  meals. 

Basic  orexin,  gr.  |  to  J  (0.02-0.03)  t.  i.  d.,  may  prove  of  service. 
Morphin  and  tobacco,  if  they  are  factors,  should  be  cut  off. 

Sanitarium  treatment  and  rest  cure  are  important  in  severe  cases, 
especially  by  the  Weir-Mitchell  method.  Isolation  from  the  family, 
strict  supervision  by  the  physician,  massage,  and  electricity  are 
valuable. 

Forced  feeding  (gavage)  or  nutritive  enemata  may  be  required. 
After  a  while  the  patient  will  be  convinced  she  can  digest  food. 
Small  quantities  are  given  at  first,  and  then  they  are  increased,  In 
milder  cases  change  of  climate  is  useful. 

Strychnin,' gr.  -i^  to  sV  (0.001-0.002),  Blaud's  iron  pills,  pepto- 
mangan  (Gude),  or  iron  tropon  are  of  service.  Arsenic  may  be 
added.  Fowler's  solution,  Hlv  (0.29),  sodium  arsenate,  gr.  eV  to  -gV 
(0.001-0.002),  glycerophosphates  of  soda,  or  Chapoteaut's  glycero- 
phosphate of  lime.     These  remedies  should  be  given  t.  i.  d. 

Sensations  "Within  the  Stomach 

Under  normal  conditions  we  do  not  recognize  that  we  have  a 
stomach,  and  there  are  no  sensations  after  the  ingestion  of  food. 
The  stomach  is  not  devoid  of  sensation  even  normally,  as  excessive 
quantities  of  hot  or  cold  material  are  noted  by  internal  sensations, 
such  as  after  the  ingestion  of  a  large  quantity  of  ice  cream  on  an 
empty  stomach. 

Gastric  sensation,  however,  may  be  increased  to  a  pathologic 
degree  and  be  a  source  of  great  discomfort.     We  must  remember 


364  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

that  certain  persons  are  peculiarly  constituted  and  have  idiosyn- 
crasies to  particular  foods. 

Idiosyncrasies. — For  example,  shell-fish,  such  as  lobsters,  crabs, 
and  oysters,  strawberries,  bananas,  onions,  etc.,  will  produce  skin 
eruptions  such  as  urticaria  or  erythema,  and  gastric  symptoms  such 
as  pain,  belching,  pressure,  and  even  nausea  or  vomiting.  Talma 
and  Einhorn  have  described  cases  having  a  peculiar  idiosyncrasy  to 
hydrochloric  acid.  I  have  seen  several  cases  where  the  patient 
suffered  from  the  symptoms  of  hyperchlorhydria,  and  yet  the  free 
hydrochloric  acid  found  was  well  within  normal  limits.  The  adminis- 
tration of  alkalis  relieved  the  symptoms.  The  gastric  nerves  were 
evidently  peculiarly  sensitive  to  acid  in  these  cases.  If  patients 
have  an  idiosyncrasy  to  special  food,  it  must  be  avoided. 

Abnormal  Sensations  (Sensory  Neuroses  of  the  Stomach) 
The  nervous  and  hysteric  at  times  complain  of  sensations  of  heat, 
cold,  or  of  some  foreign  body,  such  as  the  feeling  of  worms,  etc., 
within  the  stomach.  These  symptoms  are  not  dependent  on  the 
food  or  upon  the  gastric  secretion.  There  may  be  in  some  a  feeling 
of  constriction,  cramp,  or  "pulsation"  within  the  stomach.  The 
latter  is  probably  due  in  many  cases  to  hyperesthesia  and  the  trans- 
mission of  the  aortic  pulsation. 

Nausea.-^ -There  may  be  a  nervous  type  of  nausea  in  such  patients, 
either  during  the  fasting  condition  or  after  meals,  the  treatment 
for  which  should  be  directed  to  the  neurasthenia.  Nausea  may  also 
be  reflex,  as  from  an  affection  of  the  genital  organs  or  in  organic  disr 
ease  of  the  stomach.  Einhorn  recommends  intragastric  galvanization. 
The  indication,  however,  is  to  treat  the  hysteria  or  neurasthenia. 

Hyperesthesia  of  the  Stomach 

This  consists  in  an  increased  sensibility  of  the  nerves  of  the 
stomach,  so  that  the  mucous  membrane  is  abnormally  sensitive  even 
after  ordinary  food  is  taken.  It  differs  only  in  degree  from  gas- 
tralgia.  It  may  be  secondary  to  organic  affections,  associated  with 
secretory  disturbances,  or  it  occurs  as  a  primary  neurosis. 

Etiology. — It  is  present  especially  in  the  higher  classes.  Mental 
overexertion,  excitement,  alcohol,  and  venereal  excesses,  which 
weaken  the  constitution,  are  factors.  It  is  associated  with  hysteric 
or  nervous  symptoms.  Though  anemia  is  given  as  a  cause,  hyper- 
chlorhydria with  hyperesthesia  occur  with  this  condition,  and  this 
type  is,  therefore,  not  a  pure  sensory  neurosis. 

Symptoms. — There  is  a  sensation  of  fulness,  weight,  or  pressure 
after  meals,  which  may  become  real  pain,  and  finally  vomiting  may 
occur.  Sometimes  considerable  emaciation  is  present,  as  the  patient 
fears  to  eat  (sitophobia).  Hyperesthesia  occurs  after  excess  of  food 
or,  in  some,  in  cases  of  fasting. 


NERVOUS   AFFECTIONS   OF  THE   STOMACH  365 

Physical  Signs. — The  epigastrium  and  region  of  the  stomach 
are  sensitive  to  pressure  throughout,  but  there  is  no  specially  sensitive 
area  as  in  ulcer. 

Certain  articles  of  food,  such  as  sugar,  fat,  starch,  or  coffee,  may 
produce  the  condition.  The  secretory  and  motor  functions  are 
normal  in  the  purely  nervous  cases. 

Diagnosis. — This  is  based  on  the  absence  of  organic  disease  of 
the  stomach,  the  absence  of  hyperchlorhydria  or  of  other  secretory 
disturbances,  and  the  absence  of  motor  disturbances.  With  hyper- 
chlorhydria and  gastritis  the  gastric  analysis  and  other  symptoms 
will  give  us  the  requisite  differential  points.  With  ulcer,  hyperacid- 
ity is  the  rule,  and  the  degree  of  pain  is  dependent  considerably  on 
the  character  of  the  food,  which  is  not  generally  so  in  hyperesthesia; 
the  other  symptoms  also  differ. 

With  erosions  small  bits  of  mucous  membrane  are  washed  out  and 
there  are  secretory  changes. 

Prognosis  depends  on  the  result  of  the  treatment  of  the  nervous 
condition. 

Treatment. — In  many  of  these  cases,  as  when  anemia  is  present, 
secretory  disturbances  are  associated  with  the  sensory  neurosis,  as 
hyperchlorhydria,  so  that  the  pure  sensory  condition  is  often  com- 
plicated. Iron  and  arsenic  are  necessary  in  such  cases  and,  in  fact, 
have  an  excellent  effect.  Peptomangan,  iron  tropon,  or  any  good 
iron  preparation  combined  with  Fowler's  solution,  TTLv  (0.296  cc.) 
t.  i.  d.,  is  excellent. 

The  patient  should  be  kept  in  bed  in  severe  cases  and  warmth 
applied  to  the  stomach,  dry  heat,  or  Priessnitz  compresses.  Fluid 
diet  in  rather  small  quantity  should  first  be  given.  Milk  and  lime- 
water,  sanatogen,  broths,  chicken  soup,  white  of  egg,  later  entire 
raw  eggs  beaten  in  water,  calves'-foot  jelly,  scraped  meat,  zwieback 
softened  in  milk,  butter,  and  gradually  solid  food. 

Tincture  of  belladonna,  TTLv  to  x  (0.296-0.592)  t.  i.  d.,  is  excellent 
for  the  pain.  The  use  of  opium  and  its  derivatives  and  cocain  are  to 
be  deprecated.     Rarely  an  occasional  dose  of  codein  may  be  required. 

In  some  cases  silver  nitrate,  gr.  i  to  ^  (0.008-0.016),  in  aqueous 
solution  t.  i.  d.  before  meals  is  of  service. 

External  galvanization  to  the  stomach  is  of  value.  Bromids  in 
some  cases  are  serviceable. 

Baths  and  change  of  scene  may  be  enjoined.  Suggestion  should 
be  used  by  the  physician. 

GASTRALGIA 

{Synonyms. — Gastrodynia,  Spasm  of  the  Stomach   (Gastrospasmus) ;  Cardialgia, 
Neuralgia  of  the  Stomach.) 

Gastralgia  may  be  defined  as  the  occurrence  of  violent  attacks 
of  pain  in  the  stomach,  paroxysmal  in  character  and  alternating 
with  free  intervals. 


366  DISEASES   OF  THE   STOMACH  AND  INTESTINES 

Etiology. — We  may  have  a  number  of  forms  of  gastralgia 
originating  from  various  conditions,  and  these  must  be  referred  to 
in  order  to  differentiate  them  from  the  purely  nervous  type. 

Gastralgia  Originating  in  the  Stomach. — (a)  Connected  with 
organic  affections,  such  as  ulcer,  cancer,  stenosis  of  the  pylorus,  or 
gastritis,  with  hyperacidity,  hypersecretion,  peritonitic  adhesions,  or 
perigastritis. 

(b)  Special  varieties  of  food,  as  rich  spices,  or  of  drink,  as  strong 
coffee,  or  ice  cream,  etc.,  may  produce  it  in  people  not  accustomed 
to  these  substances. 

Spinal  disease,  as  tabes,  may  cause  gastric  crises,  or,  more  rarely, 
cerebral  disease  or  various  types  of  myelitis.  Absence  of  patellar 
reflex,  Argyll-Robertson  pupil,  and  Rhomberg  symptom  are  diag- 
nostic of  tabes. 

Gastralgia  as  a  Neurosis. — This  occurs  with  neurasthenia  or 
hysteria.  It  may  appear  before  the  nervous  symptoms  are  in 
evidence. 

Reflex  Causes. — Gastralgia  of  this  type  occurs  most  frequently 
in  women.  It  takes  place  reflexly  from  disturbances  in  the  female 
or  in  the  male  genital  organs.  Gastralgia  may  occur  at  the  time  of 
menstruation  or  in  place  of  it. 

Disease  of  the  liver,  spleen,  bladder,  pancreas,  and  ptosis  of 
abdominal  organs  may  be  reflex  causes. 

Other  Causes. — Malarial  injection  may  be  a  cause  of  gastralgia. 
The  latter  may  be  associated  with  the  usual  symptoms  of  malaria 
or  it  may  be  substituted  for  the  malarial  cycle,  appearing  every 
day,  alternate  day,  or  third  day  at  the  same  hour,  as  do  other  neu- 
ralgias. 

Gouty  infection,  lead-  or  mercurial  poisoning,  or  excessive 
smoking  may  produce  it.  Exophthalmic  goiter,  anemia,  or  chlorosis 
with  malnutrition  may  be  a  cause,  although  the  attacks  in  many  of 
these  cases  are  the  result  of  the  associated  hyperchlorhydria. 

Sex. — Most  frequently  in  women  and  girls  from  fifteen  to  forty, 
and  decreases  in  frequency  with  age. 

Symptoms. — The  attacks  usually  appear  suddenly  and  occur 
in  paroxysms,  though  they  may  be  preceded  by  nausea,  with  belching 
and  distention,  headache,  or  dizziness.  There  is  a  sudden  extreme 
pain  in  the  epigastric  region  of  a  boring,  tearing,  burning,  and 
constricting  character.  It  may  radiate  over  the  abdomen  or  to  the 
back  and  shoulders.  The  attacks  may  occur  independently  of  eat- 
ing and  whether  the  stomach  is  empty  or  full,  or  at  any  hour  {in  the 
nervous  cases). 

The  face  is  pale  and  distorted  with  the  pain,  by  which  the  patient 
is  frequently  doubled  up,  as  with  colic,  and  there  is  inability  to  lie 
straight,  and  often  clammy  sweating.  Strong  pressure  on  the  abdo- 
men frequently  relieves  the  pain,  though  it  may  be  sensitive  to  lighter 
pressure.     The  gastric  region  is  usually  sunken. 


NERVOUS    AFFECTIONS    OF   THE    STOMACH  367 

There  are  often  hiccough  and  belching,  with  nausea  and  collapse. 
The  pulse  is  generally  rapid  and  feeble,  though  in  some  cases  slow.  . 

Duration. — Gastralgic  attacks  may  last  from  a  few  minutes  to 
an  hour  or  longer.  There  may  be  several  attacks  in  a  day,  every 
few  days,  or  at  intervals  of  weeks  or  months. 

The  pain  disappears  suddenly  and  may  be  followed  by  hunger 
or  even  bulimia.  In  mild  cases  the  patient  may  not  be  greatly 
affected  and  may  be  able  to  work  immediately,  while  in  the  severe 
cases  there  is  often  prostration  for  several  days. 

Prognosis  is  favorable  as  far  as  life,  and  depends  on  the  removal 
of  the  primary  cause. 

Differential  Diagnosis. — The  sudden  onset,  violent  spasmodic 
pain  in  the  stomach,  general  in  character  and  lessened  by  pressure, 
nausea,  vomiting,  and  headache— that  these  symptoms  are  inde- 
pendent of  eating  and  frequently  occur  after  mental  overexertion  or  emo- 
tional shock  and  are  associated  with  nervous  hysteric  symptoms — 
all  point  to  the  nervous  type. 

We  must  exclude  the  secondary  form  by  gastric  analysis,  and  by 
the  determination  that  no  organic  disease  exists.  A  careful  physical 
examination  is  necessary,  thereby  ehminatihg  other  conditions  that 
may  cause  pain  in  the  gastric  region. 

U-lcer  of  the  Stomach.— The  pain  at  the  height  of  digestion  depends 
on  the  quantity  and  quality  of  food ;  disappears  when  the  stomach  is 
empty;  intervals  free  from  pain;  hyperchlorhydria  present;  circum- 
scribed spot  in  the  epigastrium  painful  on  pressure  and  increased 
by  it;  hematemesis  present  in  some  cases,  or  occult  blood  in  gastric 
contents  or  stool.  If  these  characteristic  symptoms  are  absent  it 
may  be  necessary  to  try  one  of  the  ulcer  cures;  which,  if  it  fails, 
would  rather  point  toward  nervous  gastralgia. 

Cancer  of  the  Stomach. — Pains  not  as  severe,  but  more  continuous, 
never  free  from  pain ;  absence  of  hydrochloric  acid ;  lactic  acid  and 
Boas-Oppler  bacilli  present;  cachexia;  age  of  patient;  tumor  often 
present. 

Chronic  Gastritis. — Intense  pains  are  absent;  are  continuous  and 
more  a  sense  of  discomfort  after  the  ingestion  of  food ;  no  paroxysms ; 
mucus  in  gastric  contents;  hypochlorhydria. 

Stenosis  of  the  Pylorus. — Attacks  of  pain  (gastralgia),  associated 
with  peristaltic  unrest  and  vomiting.  Dilatation  of  the  stomach  is 
present;  usually  hyperacid  contents  if  benign  stenosis ;  and  lactic  acid 
present  with  absence  of  free  HCl  and  Boas-Oppler  bacilli  if  malignant. 

Functional  Disorders. — Hyperchlorhydria  and  hypersecretion;  pains 
disappear  after  albuminous  food  or  alkalis.  Gastric  analysis,  hy- 
peracidity; and  if  hypersecretion,  excessive  quantity  of  secretion  in 
the  empty  stomach. 

Achylia  Gastrica. — Pains  disappear  when  stomach  is  empty. 
Gastric  analysis  shows  low  acidity,  2  +  or  4  +  ;  free  HCl  absent ; 
rennet  =  o ;  pepsin  =  o. 


368  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

Rheumatism  and  Myalgia. — Myalgia  is  muscular  pain  which  may 
be  due  to  exertion.  In  both  conditions  the  pain  is  not  paroxys- 
mal; corresponds  to  the  course  of  the  muscles,  and  is  reUeved  by 
abdominal  relaxation;  we  have  rheumatic  history  or  that  of  over- 
exertion. 

Intercostal  Neuralgia. — Pain  is  superficial  and  can  be  traced  along 
the  intercostal  nerves,  which  are  sensitive  at  numerous  points  on 
pressure. 

Renal  Calculi. — Pain  in  the  kidney  (dorsal  region)  radiates  to 
the  ureter  and  bladder;  testicle  drawn  up  in  the  male;  urine  is  acid 
and  shows  blood.     Kidney  is  frequently  tender  on  pressure. 

Gall-stones. — Pain  over  liver  and  gall-bladder;  deep  pressure 
increases  the  pain;  rise  of  temperature;  pain^  passes  to  right  and 
often  up  into  the  right  shoulder.     Iveukoc3^osis  frequently  present. 

Jaundice  at  times  and  gall-stones  in  the  stool  are  conclusive. 

//  the  motor  or  secretory  functions  of  the  stomach  are  normal,  the 
attack  of  pain — especially  if  it  is  in  the  right  h^^pochondrium  and 
the  patient  has  no  nervous  symptoms — is  probably  due  to  gall-stones. 

In  gastralgia  there  is  no  pain  and  no  fever.  It  is  sometimes 
difficult  to  differentiate  between  the  other  conditions. 

Perigastritis. — A  high  position  of  the  stomach,  with  the  left  lobe 
of  the  liver  drawn  down  and  covering  that  organ,  is  suggestive  of 
perigastritis  when  pains  come  on  regularly  several  hours  after 
meals  (Kaufmann).^ 

Intestinal  Colic  (Enteralgia) . — Pain  changes  its  position  in  the 
abdominal  cavity.  Passage  of  flatus  relieves  pain.  Bowels  are 
irregular. 

Treatment. — In  secondary  gastralgia  it  is  necessary  to  treat 
the  primary  cause. 

If  it  is  due  to  tobacco,  it  should  be  cut  off.  Malaria  should  be 
treated  with  quinin  or  Warburg;  and  anemia,  with  iron  and  arsenic 
and  the  rest  cure.  Correct  a  gouty  tendency,  if  present;  or  treat 
tabes,  if  this  be  found. 

Sexual  disorders,  ulcer,  gall-bladder  disease,  or  cancer  should 
receive  appropriate  treatment. 

If  hysteria  or  neurasthenia  is  present,  tonics,  isolation,  the  rest 
cure,  massage,  and  hydrotherapy  are  of  value. 

The  galvanic  current,  the  anode  over  the  stomach,  or  intra- 
ventricular galvanization,  with  the  cathode  over  the  spinal  column, 
is  of  service  when  repeated  attacks  of  primary  gastralgia  occur. 

For  the  active  condition,  if  moderately  severe,  hot  applications 
(dry  or  moist  heat)  and  hot  drinks  are  useful. 

Tincture  of  belladonna,  TTLx  to  xv  (0.592-0.088),  to  relieve  the 
spasm.  Tincture  of  valerian,  Tllxx  to  3ss  (i.  184-2.0),  in  water,  or 
Hoffmann's  anodyne,  3ss  (2.0),  may  be  given  in  water  with  sugar. 

1  Head's  gall-bladder  zone  often  present. 

2  American  Medicine,  vol.  vi,  No.  20,  pp.  792,  794,  Nov.  14,  1903. 


NERVOUS  AFFECTIONS   OP   THE)   STOMACH  369 

Chloroform  spirits,  2  to  3  drops  in  water  at  a  dose,  can  be  admin- 
istered.    The  bromids  are  also  valuable. 

If  there  is  retention  of  food  during  the  attack,  then  lavage  with 
hot  water  will  relieve  some  cases. 

If  the  pain  is  unbearable,  codein,  gr.  h  (0.032),  by  hypodermic, 
or  morphin,  gr.  \  (0.016),  with  atropin,  gr.  1^^  (0.00065),  can  be 
administered. 

Suppositories  of  morphin,  gr.  \  (0.016),  and  extract  of  belladonna, 
gr.  \  (0.016),  or  opium,  gr.  i  (0.065),  ^^id  extract  of  belladonna, 
gr.  \  (0.016),  every  two  to  three  hours  for  several  doses,  are  useful. 

Gastralgokenosis  (Boas^) 
This  is  characterized  by  pain  in  the  stomach  when  it  becomes 
empty,  and  is  relieved  by  food.     It  may  be  periodic  or  permanent. 
Frequent  meals  and  nerve  sedatives  are  required. 

MOTOR  NEUROSES   OF  THE  STOMACH 

Under  normal  conditions  the  cardia  remains  closed  after  the 
process  of  digestion  has  begun,  while  the  pylorus  opens  at  intervals 
to  allow  a  certain  amount  of  escape  of  chyme.  The  muscular 
movements  of  the  stomach  mix  the  ingesta  with  the  gastric  juice 
and  aid  in  its  disintegration  by  churning  movements.  Later  they 
propel  it  into  the  intestine.  These  motor  functions  may  be  irritated 
(exaggerated)  or  depressed  (diminished). 

Hypermotility  of  the  Stomach 

{Synonyms. — Supermotility;      Hyperkinesis;       Hyperanakinesis        Ventriculi — 

Einhorn). 

In  this  condition  the  stomach  propels  the  ingesta  into  the  intestine 
more  rapidly  than  normally.  It  may  be  secondary  to  achylia  gastrica 
or  hyperchlorhydria  or  diseases  complicated  thereby,  or  the  condition 
may  exist  as  a  primary  neurosis. 

In  some  cases  achylia  and  hyperchlorhydria  exist  as  a  secretory 
neurosis,  and  with  this  there  is  the  motor  neurosis,  hypermotility. 

Supermotility  may  exist  as  a  motor  neurosis  alone  (primary 
neurosis) ,  due  to  some  nervous  influence  or  associated  with  nervous 
conditions,  and  is  analogous  to  increased  intestinal  peristalsis  from 
nerv^ous  influence.  In  pyloric  obstruction  there  is  often  actual 
increased  motor  power  in  the  early  stages,  but  the  resistance  to 
the  exit  is  so  increased  that  the  final  result  is  relative  motor  insuf- 
ficiency. In  the  secondary  cases  hypermotility  will  be  relieved  by 
treating  the  cause. 

Diagnosis. — Aspiration  of  the  stomach  contents  will  demon- 
strate the  condition.  For  example,  one  may  find  the  stomach 
empty  thirty-five  to  forty-five  minutes  after  the  test  breakfast,  or 
only  a  minute  quantity  can  be  removed. 

1  Boas,  Krank.  des  Magen,  II,  Feb.  418,  Auflage,  S.  260,  Leipzig,  1901. 
24 


370  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Einhorn  suggests  the  employment  of  the  gastrograph,  noting 
an  increase  of  the  "makes"  and  "breaks,"  but  this  method  is 
complicated. 

Careful  analysis  of  the  gastric  contents  should  be  made  to  test 
the  secretory  functions,  and  an  early  aspiration  would  be  necessary. 

Hypermotility  in  itself  does  not  produce  any  special  gastric 
symptoms. 

Peristaltic  Restlessness  of  the  Stomach  (Kussmaul) 

{Synonyms. — Peristaltic  Unrest;  Tormina  Ventriculi  Nervosa.) 

This  is  really  an  exaggerated  hypermotility  in  which  the  peristaltic 
action  is  unusually  great,  and  is  appreciated  by  the  patient  as  a 
disagreeable  sensation.  It  may  even  become  visible  through  the 
walls  of  the  abdomen,  and  waves  of  contraction  can  be  seen  running 
from  left  to  right  along  the  stomach,  and  may  take  from  three- 
quarters  of  a  minute  to  a  minute  or  more.  This  condition  usually 
occurs  when  there  is  obstruction  at  the  pylorus  or  duodenum,  with 
dilatation  of  the  stomach,  and  is  produced  by  the  effort  of  the  organ 
to  overcome  the  obstruction. 

Kussmaul  first  described  2  cases  of  peristaltic  unrest  which  were 
pure  neuroses  of  motility.  The  movements  began  early  in  the 
empty  stomach  and  became  more  violent  after  eating.  Gastroptosis 
was  present. 

Emotional  shock  and  abuse  from  sexual  excesses  were  the  causes. 

Mechanical  forms  must  be  excluded.  In  these  it  occurs  only  when 
the  stomach  is  full.  In  the  nervous  cases  movements  take  place 
both  when  the  stomach  is  full  and  empty.  If  the  patient  is  well 
nourished  and  the  stomach  is  in  normal  position  it  may  be  diffi- 
cult or  impossible  to  see  the  movements,  but  the  patient  will  com- 
plain of  the  contractions  and  wave-like  movements,  and  borborygmi 
and  gurgling  may  be  heard.  Nausea,  vomiting,  and  cramp-like 
pains  mav  occur,  especially  in  the  obstructive  type. 

Physical  examination  and  gastric  analysis  will  determine  whether 
the  peristaltic  restlessness  is  primary  (a  neurosis)  or  secondary. 

Course  and  prognosis  depend  upon  the  cause  and  the  nervous 
condition  in  primary  cases. 

Cases  may  be  continuous,  when  they  may  cause  loss  of  sleep,  or 
may  be  intermittent. 

Treatment. — This  must  be  directed  against  the  primary  cause, 
such  as  stenosis  of  the  pylorus,  etc. 

If  it  is  a  pure  gastric  neurosis,  resulting  from  mental  overexertion, 
grief,  sexual  excess,  or  nervous  or  hysteric  conditions,  we  must 
remove  these  factors.  Iron,  arsenic,  and  the  glycerophosphates  are 
indicated. 

Hydrotherapy,  diet,  and  change  of  scene  are  valuable.  The 
diet  should  be  regulated,   all  irritants  to  the  stomach  should  be 


NERVOUS   AFFECTIONS    OF   THE    STOMACH  371 

avoided.  The  food  should  be  digestible,  non-irritating,  and  in 
moderate  quantities  at  a  time,  especially  at  night. 

Locally,  heat  or  cold  to  the  stomach;  galvanic  electricity,  per- 
cutaneous or  intragastric.  This  last  is  of  no  value  in  stenotic  cases, 
but  does  harm. 

Lavage  is  indicated  if  there  are  stenosis  and  dilatation. 

Antiperistaltic  Restlessness  of  the  Stomach 
In  rare  cases  the  peristaltic  action  is  reversed,  the  waves  running 
from  right  to  left.     These  cases  are  generally  of  neurotic  origin. 

Intestinal   waves   are   of   small   caliber   and   move   in   different 
directions  in  various  regions,  while  gastric  waves  are  of  large  size  and 
move  in  the  gastric  region.     These  waves  may  extend  to  the  intestines 
and  colored  enemata  have  been  voided  from  the  mouth  (Osier). 
Treatment  should  be  directed  to  the  neurosis. 

Incontinence  of  the  Pylorus 

{Synonyms. — Insufficiency  of  the  Pylorus.) 

This  condition  was  first  described  by  de  Sere  and  Ebstein. 

It  may  be  caused  by  some  growth  in  the  pylorus,  keeping  the 
opening  patent,  or  by  stenosis  or  other  organic  changes,  or  when  the 
pylorus  is  relaxed  (atonic)  due  to  some  nervous  derangement, 
hysteria,  or  myelitis. 

Relaxed  pylorus,  1  believe,  to  be  frequently  associated  with 
atonic  ectasy,  and  that  this  feature  accounts  for  the  absence  of  pain 
and  vomiting.  It  is  also  present  in  some  cases  of  gastroptosis. 
The  relaxation  in  these  cases  is  probably  compensatorv. 

Ebstein^  has  shown  that  if  we  attempt  to  inflate  the  stomach  with 
air  or  CO2,  it  will  rapidly  pass  into  the  intestine  and  distend  it,  and 
gastric  tympany  is  absent.  A  diagnostic  feature  is"ihe  regurgitation 
of  the  intestinal  contents  into  the  stomach.  On  aspiration  or  lavage 
in  the  fasting  condition,  intestinal  juice  and  often  a  considerable 
quantity  of  bile  will  be  found.  It  is  sometimes  present  on  aspiration 
of  the  test  breakfast  or  test  meal.  Very  little  chyme  is  present  in 
these  cases,  but  regurgitation  is  in  evidence. 

There  are  no  distinctive  clinical  symptoms  in  most  cases;  though 
Knapp^  reports  diarrhea  alone  or  alternating  with  constipation,  as 
sometimes  associated,  and  also  toxemic  symptoms,  as  does  Ebstein; 
and  Einhorn  refers  to  2  cases  in  which  there  was  associated  cardiac 
relaxation,  with  belching  as  the  chief  symptom.  My  prolonged  in- 
vestigations among  the  nervous  and  insane  lead  me  to  absolutely 
disagree  with  Knapp  that  achylia  (functional  or  organic)  and  in- 
sufficiency of  the  pylorus  are  confounded.  This  author  believes 
there  is  no  functional  achylia,  and  with  this  I  entirely  disagree. 

1  The  relaxation  in  these  cases  I  do  not  believe  to  be  a  true  incontinence,  but 
merely  atony  with  weakening  of  the  pyloric  musculature,  with  no  regurgitation. 
-  Philadelphia  Medical  Journal,  May  24,  1902. 


372  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Treatment. — Occasional  lavage;  strychnin,  gr.  4V  (0.00146), 
and  belladonna  extract,  gr.  J  (0.0 11)  t.  i.  d.,  with  intragastric 
faradization  (every  other  day). 

Massage  and  douches  are  serviceable. 

Spasm  of  the  Pylorus  (Pylorospasmus) 

Spasm  of  the  pylorus  is  usually  a  secondary  occurrence,  asso- 
ciated with  hyperchlorhydria,  hypersecretion,  ulcer  of  the  pylorus, 
or  in  its  immediate  neighborhood;  and  in  the  latter  case  must  be 
considered  a  reflex  neurosis.  It  may  result  from  irritation  of  the 
stomach  by  indigestible  diet,  by  food  that  is  too  hot  or  cold,  or  by 
strong  spices,  etc.  It  is  rare  with  carcinoma  with  abundant  lactic 
acid. 

Bentijac^  described  a  case  who  drank  a  glass  of  kerosene  by  mis- 
take, and  who  later  developed  all  the  symptoms  of  stenosis  of  the 
pylorus  and  dilatation. 

Operation  showed  the  pylorus  normal,  but  spasmodically  con- 
tracted.    Vomiting  ceased  after  operation. 

Repeated  spasm  of  the  pylorus,  in  conjunction  with  hyperacidity 
or  hypersecretion,  is  undoubtedly  at  times  the  cause  of  gastric 
dilatation ;  and  in  some  cases  benign  stenosis  may  result  from  hyper- 
trophy at  the  pylorus  caused  by  repeated  spasm. 

Symptoms. — Pain,  increased  peristalsis  of  the  stomach,  and 
occasionally  vomiting  are  present. 

Pure  nervous  spasm  of  the  pylorus  is  difficult  to  diagnose.  All 
perversions  of  secretion  and  all  mechanical  obstacles  must  be  ex- 
cluded. Nervous  pyloric  spasm  is  most  likel)^  to  be  associated 
with  the  hysteric  or  neurasthenic  condition. 

Treatment. — Belladonna  is  of  value;  the  tincture,  lUx  (0.592) 
t.  i.  d.,  or  extract,  gr.  ^  (0.016)  three  or  four  times  a  day. 

The  nervous  system  must  be  treated.  In  the  secondary  cases, 
secretory  perversions  and  other  causes  of  the  condition  must  receive 
appropriate  treatment. 

Atony  of  the  Stomach 

This  is  a  condition  in  which  the  muscular  action  of  the  stomach 
is  retarded  and  weakened,  and  moderate  motor  insufficiency  results. 
It  may  be  acute  or  chronic  and  secondary  to  other  conditions,  or  as  a 
primary  neurosis.     It  has  been  already  fully  described. 

Hypanakinesis  Ventriculi  (Einhorn) 
is  defined  as  a  condition  in  which  the  mechanical  function  of  the 
stomach  is  greatly  reduced.  There  are  no  breaks,  or  few,  in  the 
gastrograph,  an  instrument  to  determine  the  churning  movements 
of  the  stomach.  It  seems  a  minor  degree  of  atony,  and  is  of  no 
Special  clinical  significance. 

1  These  de  Paris,  1888. 


nervous  affections  of  the  stomach   '  373 

Hyperanakinesis  Ventriculi  (Einhorn) 

This  is  an  excessive  mechanical  action  of  the  stomach.  It  seems 
to  correspond  to  hypermotihty.  Excessively  active  churning  move- 
ments occur  in  this  condition  (Einhorn).  It  seems  difficult  to  sepa- 
rate it  from  hypermotihty. 

Spasm  of  the  Cardia  (Cardiospasmus) 

Spasm  of  the  cardia  consists  in  a  spasmodic  contraction  of  the 
muscles  of  the  cardia,  with  the  production  of  pain  and  difificulty  in 
swallowing  (dysphagia).  It  may  be  secondary  to  other  diseases 
(organic  disease),  reflex  from  local  irritation,  or  as  a  primary  neurosis, 
associated  with  nervous  conditions. 

Etiology. — It  may  be  produced  by  the  passage  of  the  stomach- 
tube  or  after  rapid  eating,  by  very  hot  or  cold  drinks,  and  by  coarse 
or  hard  food. 

Among  other  causes  are  ulcer  or  carcinoma  of  the  cardia.  Hyper- 
acidity may  occasionally  cause  it,  though  pyloric  spasm  is  more 
frequent  with  this  affection.  Diverticula,  or  inflammation  of  the 
esophagus,  are  causes.  It  may  occur  in  tetanus.  It  is  quite  frequent 
in  hysteric  or  neurasthenic  individuals,  especially  in  air  swallowers 
(aerophagia),  in  whom  spasm  of  the  pylorus  may  also  occur  with 
resulting  distention  of  the  stomach  ("pneumatosis").  Violent 
psychic  shocks  may  also  produce  it,  so  the  condition  may  be  a 
primary  neurosis.  Fermentative  processes  in  the  stomach,  with 
the  production  of  gas,  may  be  a  cause ;  but  organic  disease  is  usually 
associated.  Primary  spasm  of  the  cardia  cannot  produce  gastric  dis- 
tention unless  spasm  of  the  pylorus  is  also  present. 

S5niiptoms. — As  a  pure  neurosis  the  attack  usually  begins 
suddenly.  The  patient  may  be  in  perfect  health,  when  an  acute 
pain  begins  in  the  region  of  the  cardia  radiating  tow^ard  the  chest 
or  back.  It  occurs  generally  during  the  ingestion  of  food,  and  there 
is  a  feeling  as  if  some  of  it  were  arrested.  There  is  at  times  some 
interference  with  breathing.  Slight  dyspnea  is  present  and  the 
respiratory  movements  are  more  forcible.  There  may  be  regurgi- 
tation and  the  patient  feels  better  thereafter.  There  is  gagging  and 
often  vomiting. 

The  attack  can  be  acute  and  last  only  a  short  time  or  the  con- 
dition may  become  chronic.  The  dysphagia  in  these  cases,  as  a  rule, 
increases;  and  though  for  a  time  the  patient,  by  taking  a  deep  inspira- 
tion and  compressing  the  thorax  while  holding  his  breath,  can  force 
down  the  food,  the  deglutition  of  soHd  food  becomes  more  and  more 
difficult,  and  finally  only  liquids  can  be  taken.  Emaciation  may 
become  quite  marked,  and  after  several  years  atonic  dilatation  of 
the  esophagus  may  result  similar  in  character  to  atonic  gastric 
dilatation  from  pyloric  spasm.  Dilatation  of  the  esophagus  may  also 
be  produced   by  benign  or  malignant  stenosis  at  the  cardia;  or  by 


374  DISEASES    OF   THE   STOMACH   AND   INTESTINES 

paralysis  of  the  dilator  nerves  of  the  cardia,  from  paralysis  of  the 
esophagus,  or  by  loss  of  reflex  relaxation  of  the  cardia  (Einhorn). 

Diagnosis. — In  acute  cases  the  existence  of  pain  and  dysphagia, 
the  delay  or  absence  of  the  swallowing  sound,  and  the  spasmodic 
resistance  at  the  cardia  on  insertion  of  the  stomach-tube,  which 
can  be  overcome  by  pressure,  together  with  the  presence  of  neu- 
rasthenia or  hysteria,  settle  the  diagnosis. 

In  the  chronic  type  the  history  of  the  case,  the  fact  that  often 
the  resistance  to  the  large  tube  is  less  than  to  the  small  one  in  nervous 
cases,  all  aid  the  diagnosis. 

In  true  stenosis  (organic  stricture)  the  small  sounds  are  more 
readily  passed.  The  method  of  determining  esophageal  stricture 
has  been  described.  If  blood  appears  with  the  sound,  ulceration  is 
at  once  suggested.  Cachexia  is  suggestive  of  mahgnancy,  and  aspira- 
tion of  the  gastric  contents  will  settle  the  question.  Dilatation  of  the 
esophagus  can  be  further  determined  as  follows : 

A  slice  of  bread  can  be  dissolved  in  200  cc.  of  water  to  form  a  soft 
mass,  and  administered,  the  patient  being  instructed  to  employ 
forcing  movements,  so  that  it  will  enter  the  stomach.  An  hour 
later  200  cc.  of  water  may  be  given,  no  forcing  movements  to  be 
employed.  In  about  three  to  five  minutes  an  aspirating  tube  can 
be  passed  to  the  cardia,  and  if  dilatation  and  spasm  exist  the  water 
just  ingested  can  be  removed,  and  will  be  in  the  same  condition  as 
taken.  The  tube  can  then  be  forced  on  into  the  stomach  and  the 
true  gastric  contents  can  be  removed.  These  can  be  tested.  The 
administration  of  bismuth  with  the  employment  of  the  x-rays  is 
also  of  value  for  the  purpose  of  diagnosis. 

Prognosis  is  good  in  the  acute  cases,  but  as  regards  complete 
cure  in  chronic  cases  it  is  not  so  good,  though  there  is  no  danger  to 
Ufe. 

Treatment. — If  the  spasm  occurs  while  eating  and  drinking, 
this  should  be  performed  slowly.  The  food  should  be  well  masticated 
or  should  be,  preferably,  soft  in  character;  and  excessively  hot  or 
cold  food  should  be  avoided. 

General  tonics  should  be  given.  The  employment  of  sounds,  left 
in  place  for  some  time,  is  of  value. 

Tincture  of  belladonna,  TTLx  (0.592),  should  be  given  t.  i.  d.  to 
relieve  spasm.  The  bromids  are  of  service;  thus,  sodium  bromid, 
gr.  15  to  30  (1.0-2.0)  t.  i.  d. 

Opium  or  chloral  should  be  administered  with  caution,  or  not  at  all. 

In  the  chronic  cases  soft  or  liquid  food  should  be  given.  The 
patient  should  bear  down  to  force  the  food  thoroughly  by  the  ob- 
struction. The  stomach-tube  should  be  introduced  at  least  once  a 
day  to  relax  the  cardia;  if  there  is  emaciation,  food  can  be  admin- 
istered through  the  tube;  if  the  esophagus  is  dilated,  it  can  be 
emptied  and  washed  out.  Rectal  feeding  must  be  enjoined  for  a  time 
in  severe  cases.     As  improvement  occurs  the  diet  can  be  increased. 


nervous  affections  of  the  stomach  375 

Insufficiency  of  the  Cardia 

Under  this  we  may  classify  eructation,  pyrosis,  regurgitation,  and 
rumination. 

Eructation  (Belching). — Eructation  may  be  defined  as  the 
expulsion  of  gas  from  the  stomach  through  the  mouth. 

The  condition  may  be  secondary  to  various  conditions  of  the 
stomach  or  may  be  a  primary  neurosis. 

Normal  healthy  subjects  may  eructate  after  drinking  carbonated 
water,  or  those  who  eat  rapidly  without  proper  mastication,  and 
thus  swallow  considerable  air. 

Secondary  Cases.- — Belching  may  be  associated  with  acute  or 
chronic  gastritis  or  with  fermentative  processes  in  the  stomach. 

The  clinical  symptoms,  gastric  analysis,  and  fermentation  test 
will  render  a  positive  diagnosis. 

In  fermentative  processes  the  gas  is  often  malodorous. 

Primary  Cases. — Nervous  Belching  (Eructatio  Nervosa). — We 
have  cases  in  which  belching  occurs  at  short  intervals,  which  is 
independent  of  the  character  of  the  food  and  clearly  of  nervous 
origin.  It  is  noisy,  as  a  rule,  and  may  persist  for  a  considerable 
period  or  occur  in  paroxysms. 

The  gas  consists  of  atmospheric  air  which  has  been  swallowed 
(aerophagia)  or  aspirated  into  the  stomach. 

Oser  claims  that  the  stomach  acts  as  an  elastic  sac,  and  can 
aspirate  the  air  without  the  effort  at  swallowing,  and  that  it  tends 
to  fill  after  expulsion.  Some  of  the  air  probably  comes  from  the 
esophagus  and  has  been  swallowed  just  previous  to  the  act  of  belch- 
ing.    Bouveret  considers  it  due  to  spasm  of  the  pharynx.  . 

Etiology. — This  nervous  type  of  eructation  is  observed  in  hysteric 
women  and  chiefly  in  neurasthenics,  or  after  excitement,  shock,  or 
mental  worry.  It  frequently  occurs  in  children,  often  in  several 
in  a  family. 

The  belching  may  last  for  a  long  period  and  only  occur  during  the 
day,  and  may  be  extremely  annoying. 

Diagnosis. — Absence  of  fermentation,  as  shown  by  the  test, 
the  history  of  nervousness  or  of  shock,  and  the  gastric  analysis  show- 
ing normal  secretion  render  the  diagnosis  conclusive. 

Treatment. — Massage,  hydrotherapy,  iron  and  arsenic,  change 
of  climate,  the  faradic  current  (extraventricular  or  intragastric), 
bromids,  and  suggestion  to  the  patient  are  of  service. 

Pyrosis  (Heart-burn) 

This  consists  in  the  ejection  of  chyme  from  the  stomach  into  the 
esophagus,  with  which  is  associated  a  burning  sensation  in  the 
epigastrium. 

Etiology. — It  most  frequently  occurs  with  hyperchlorhydria, 
but  has  been  found  with  achylia. 


376  DISEASES   OE  THE   STOMACH  AND  INTESTINES 

It  may  occur  as  a  neurosis,  especially  among  the  hysteric  or 
neurasthenic,  with  normal  gastric  contents.  It  is  of  mixed  type, 
motor  and  sensory. 

General  tonics  and  electricity  are  of  value  in  these  cases. 

REGURGITATION 

Regurgitation  denotes  the  condition  in  which  after  eating,  some 
of  the  food  ingested,  Hquid  or  liquid  and  solid,  rises  from  the  stomach, 
enters  the  mouth,  and  is  ejected. 

Occasionally  small  fragments  are  swallowed  again.  The  act  is 
usually  involuntary,  though  it  can  be  produced  by  some  at  will. 
Early  regurgitation  tastes  of  the  food,  later  it  is  acid.  The  patients 
can  suppress  it  at  will,  and  in  this  way  it  differs  from  regurgitation 
due  to  cardiac  stenosis  or  diverticula. 

The  sound  and  chemic  analysis  also  give  aid  in  diagnosis.  In 
some  cases,  if  regurgitation  is  marked,  considerable  emaciation  may 
result. 

Organic  disease,  such  as  stricture  of  the  esophagus,  must  be 
excluded;  also  gastritis. 

Etiology.— Patients  of  nervous  or  hysteric  type  develop  this 
condition;  and  mental  worry  and  nervous  strain  may  be  the  cause. 

Prognosis  is  good. 

Treatment. — The  patient  should  eat  slowly  and  masticate  his 
food.  Suggestion  is  good;  also  forbid  the  patient  to  spit  out  his 
food,  and  tell  him  to  swallow  it  again. 

Massage,  faradization  (intra-  and  extragastric) ;  strychnin, 
gr.  -j^Q-  (0.0016)  t.  i.  d.,  and  the  treatment  of  the  nervous  condition 
are  indicated. 

Rumination  , 

{Synonyms. — Merycism,  "Chewing  the  cud.") 

In  this  condition  the  food  is  returned  from  the  stomach,  without 
nausea,  into  the  mouth,  some  time  after  meals,  where  it  is  chewed 
and  swallowed  again. 

Etiology. — It  occurs  more  frequently  in  men  than  in  women; 
and  most  of  the  cases  reported  belong  to  the  higher  classes,  especially 
among  professional  men. 

Many  of  the  lower  class  would  not  deem  the  condition  abnormal 
and  women  would  conceal  it,  so  it  may  be  said  to  belong  to  all  classes. 
It  occurs  among  hysteric  persons,  neurasthenics,  epileptics,  and 
idiots. 

Possibly  heredity  and,  undoubtedly,  imitation  in  many  cases 
are  factors.  Occasionally  there  may  be  a  pathologic  condition  of 
the  stomach,  with  regurgitation,  and  rumination  follows.  Several 
cases  have  been  reported  of  imitation  among  children. 

Shock,  trauma,  rapid  eating,  and  emotional  disturbances  in 
nervous  persons  are  at  times  accessory  factors. 


NERVOUS   AFFECTIONS   OF   THE   STOMACH  377 

Gastric  Findings. — In  some  cases  hyperacidity  has  been  found, 
and  rumination  diminished  after  this  was  corrected. 

Diminished  acidity  has  been  found  by  Boas,  and  improvement 
followed  after  hydrochloric  acid  was  administered. 

On  the  other  hand,  achylia  gastrica  has  been  present  in  such 
cases  and  also  normal  secretion. 

The  motor  functions  are  normal  in  most  cases. 

Prognosis. — ^The  habit  may  be  corrected  in  part,  but  may 
persist  for  years,  with  no  impairment  of  health.  In  some  patients 
the  attacks  are  periodic. 

Treatment. — Any  secretory  anomaly  that  exists  must  be  cor- 
rected. The  treatment  should  be  by  mental  impression  (psychic) 
on  the  part  of  the  physician.  The  patient  should  be  taught  that  he 
can  readily  suppress  the  condition.  Small  bits  of  ice  after  meals; 
lavage  and  gavage  have  been  suggested.  The  nervousness  should  be 
corrected  by  iron,  strychnin,  and  arsenic. 

Nervous  vomiting  (Vomitus  Nervosa) 

Vomiting  is  a  complex  process.  There  is  a  contraction  of  the 
abdominal  muscles  and  fixation  of  the  diaphragm,  with  a  contraction 
of  the  stomach,  accompanied  by  closure  of  the  pylorus  and  opening 
of  the  cardia;  reversed  peristalsis  of  the  esophagus  and  closure  of 
the  larynx  and  posterior  nares,  with  resulting  expulsion  of  the  stomach 
contents  through  the  mouth.  The  vomiting  center  lies  in  the  medulla 
near  the  vagus  center. 

Vomiting  may  be  due  to  some  organic  disease  of  the  stomach  or 
as  a  result  of  irritation  due  to  the  ingestion  of  food  of  abnormal 
character.  Certain  intoxications,  as  from  uremia,  cholemia,  opium, 
morphin,  tobacco,  ether,  or  chloroform,  may  produce  vomiting. 

Nervous  vomiting  is  characterized  by  the  absence  of  these  con- 
ditions just  mentioned,  and  may  be  either  cerebral  or  spinal  in 
origin,  or  due  to  reflex  disturbance,  overexertion,  emotional  shock, 
anger,  fright,  or  neurasthenia. 

Among  the  cerebral  causes  are  organic  disease  of  the  brain  and 
its- meninges,  concussion,  and  tumors. 

Spinal  forms,  such  as  tabes,  or  occasionally  paresis,  multiple 
sclerosis,  and  subacute  myelitis. 

Reflex  causes,  such  as  from  the  pharynx,  larynx,  palate,  liver, 
peritoneum,  kidneys,  genitals,  etc.  Juvenile  vomiting  and  the 
periodic  or  cyclic  vomiting  (Leyden),  also  the  cyclic  vomiting  of 
children  (infants)  are  included. 

Characteristics  of  Nervous  Vomiting. — Stiller  calls  attention 
to  the  following  peculiarities: 

This  type  of  vomiting  seems  to  he  independent  of  the  character 
and  quality  of  the  food,  and  occurs  generally  without  any  premonitory 
symptoms.  Sometimes  digestible  foods  are  vomited,  while  indiges- 
tible material  is  well  borne.     There  seems  at  times  to  be  a  power  of 


378  DISEASES   OF  THE   STOMACH   AND   INTESTINES 

selection  to  vomit  certain  nutrients,  and  the  patients  suffer  from 
no  inanition.  Vomiting  may  also  occur  from  the  empty  stomach,  and 
the  condition  is  associated  with  various  nervous  symptoms. 

Boas  has  noted  that  the  motor  and  secretory  functions  are 
normal,  though  Bouveret  and  Einhorn  have  observed  a  diminution 
or  absence  of  secretory  function  in  some  cases. 

Treatment. — Tonics.  Correct  disturbance  of  secretory  functions. 
Mental  impression  on  the  part  of  the  physician  is  important.  Change 
of  scene  is  at  times  of  value. 

Periodic  Vomiting  (Von  Leyden) 

There  are  several  particulars  connected  with  this  type  of  vomiting. 
As  a  rule,  no  cause  can  be  discovered,  and  the  attack  appears  when  the 
patient  is  in  perfect  health.  The  attacks  occur  at  intervals  of  equal 
duration.  After  the  attack  the  patient  is  immediately  restored  to 
health,  and  remains  well  until  the  next  one  occurs. 

They  resemble  somewhat  the  gastric  crises  of  tabes,  and  are 
similar  in  suddenness  of  occurrence  to  violent  attacks  of  migraine. 
They  seem  to  be  influenced  by  emotional  disturbances.  They  begin 
with  slight  nausea  and  with  a  chilly  feeling  and  headache  followed 
by  vomiting  of  the  gastric  contents,  and  later  bile  and  mucus 
streaked  with  blood. 

The  vomiting  is  very  persistent,  and  all  food  or  even  small  quanti- 
ties of  water  are  ejected.  In  some  cases  there  is  pain.  The  patient 
becomes  greatly  prostrated,  the  abdomen  sunken,  and  the  face  pale. 
The  attack  may  last  from  a  day  to  a  week  or  longer.  Suddenly  the 
nausea  and  vomiting  cease,  the  appetite  returns,  and  the  patient  is 
rapidly  restored  to  health. 

Gastric  Juice. — This  has  been  found  to  be  normal  in  most  cases, 
though  Einhorn  reports  a  case  of  achylia  gastrica. 

Treatment. — Rest,  ice  pellets,  morphin,  gr.  \  (0.016),  by  hypo- 
dermic, and  belladonna  tincture,  Hlx  (0.59),  are  useful.  Cocain  I 
deprecate.  Tincture  of  hyoscyamus,  2  cc.  (30  drops),  and  hot  appli- 
cations during  attacks.  Oxalate  of  cerium  in  grain  doses  is  of  value. 
Between  attacks,  tonics,  change  of  climate,  and  hydrotherapy. 

Cyclic  Vomiting  in  Children 

This  is  probably  due  to  faulty  metabolism;  occurs  generally  in 
those  from  two  to  four  years  of  age,  of  a  nervous  type  and  gouty 
family  history. 

There  are  premonitory  symptoms;  temperature  but  seldom  over 
100.5°  F.,  anorexia,  languor,  followed  by  persistent  and  violent 
vomiting  of  food,  mucus  streaked  with  blood,  and  at  times  bile. 
Prostration  is  marked;  the  gastric  contents  very  acid.  Acetone, 
diacetic  acid,  and  oxybutyric  acid  are  present  in  the  urine,  and  so 
it  is  believed  it  is  a  form  of  acid  intoxication ;  uric  acid  in  the  urine 
is  diminished.     It  is  possibly  a  lithemic  manifestation. 


NERVOUS    AFFECTIONS    OF    THE    STOMACH  379 

The  attack  resembles  migraine  in  the  adult.  Antecedents  are  a 
neurotic  and  gouty  family  history.  Carbohydrates  in  excess  seem 
to  have  a  bearing  on  its  production,  according  to  some;  fatigue, 
excitement,  or  tonsillitis  bring  it  on. 

Prognosis. — Good. 

Diagnosis. — Attacks  are  not  brought  on  by  indigestible  food; 
the  disease  is  self-limited,  and  the  child  rapidly  returns  to  the  normal 
state.     The  attacks  are  repeated. 

Treatment. — Calomel  to  abort  it;  food  and  drink  should  be 
stopped;  enemata  and  enteroclysis  are  advisable.  Hypodermoclysis 
may  be  necessary  in  severe  cases  and  rectal  feeding  is  indicated. 

Alkaline  Treatment. — Sodium  bicarbonate,  gr.  15  to  30  (1.0-2.0), 
in  divided  doses  may  be  given. 

Limit  starchy  food.  Care  must  be  taken  not  to  tire  the  child 
thereafter. 

Juvenile  Vomiting 

Overwork  at  school  is  often  the  cause.  Cardialgia  and  vomiting 
occur. 

There  may  be  headache,  slow  pulse,  pallor,  dilatation^  of  pupils, 
etc. 

Treatment. — Tonics,  proper  diet,  removal  from  school. 

REFLEX  VOMITING 

Nervous  vomiting  is  frequently  reflex  in  character  from  disease 
of  almost  any  organ.  Among  the  causes  are  disease  of  the  pharynx, 
elongated  uvula,  diseases  of  the  abdominal  organs,  as  hydronephrosis, 
movable  kidney,  kidney  colic,  ptosis  of  the  liver  or  spleen,  peritonitis, 
appendicitis,  hernia,  and  disease  of  the  sexual  organs.  These 
conditions  should  receive  appropriate  treatment. 

The  vomiting  of  pregnancy  belongs  to  this  type. 

Belladonna  tincture,  TTLx  (0.59),  t.  i.  d.;  cerium  oxalate,  gr.  2 
(0.13),  t.  i.  d.;  Fowler's  solution  of  arsenic,  several  doses  i  drop 
each;  bromids,  gr.  15  (i.o);  codein,  gr.  ^  (0.016);  or  chloral,  gr.  3 
(0.194),  t.  i.  d. 

I^.     Menthol gr.  x  (0.6) 

Syrup o  ij  (60.0) 

Aq.  destil q.  s.  giv  (125.0). — M. 

Sig. — Two  teaspoonfuls  t.  i.  d. 

The  use  of  cocain  I  deprecate.     Lavage  is  temporarily  of  service. 
Abortion    may   occasionally   be    required    in    pregnancy    cases. 
Change  of  scene  may  be  necessary. 

Idiopathic  Nervous  Vomiting 
In  some  hysteric  or  neurasthenic  persons  (adults)  vomiting  will 
occur   after   meals   without   any   apparent   cause,   more   frequently 
in  women  and  without  showing  the  periodic  type.     Usually  part  of 


380  DISKASES   OI?  THK   STOMACH  AND  INTESTINES 

the  meal  is  vomited.  It  may  continue  for  a  long  period.  Nutrition 
is  frequently  not  disturbed.  The  vomiting  may  occur  so  quickly 
during  the  act  of  ingestion  of  food  that  it  seems  as  if  it  did  not  enter 
the  stomach,  but  was  rejected  by  the  esophagus.  Other  patients 
seem  normal  in  this  regard. 

Occasionally  hysteric  subjects  may  vomit  blood.  In  all  cases 
the  gastric  secretion  must  be  studied,  so  as  to  exclude  hyperchlor- 
hydria,  hypersecretion,  etc.,  and  to  observe  whether  vomiting 
complicates  some  other  disease  or  is  a  reflex  affection. 

Treatment. — Suggestion,  the  regulation  of  the  mode  of  life, 
tonics,  such  as  arsenic  and  iron,  bromids;  change  of  climate;  gavage 
for  about  two  weeks;  lavage  with  i:  1000  nitrate  of  silver,  have 
proved  of  value. 

Faradization,  extra-abdominal  or  intragastric  (Einhorn),  has 
been  of  benefit. 

Pneumatosis 

Spasm  of  the  cardia,  combined  with  pyloric  spasm,  may  produce 
pneumatosis  (distention  of  the  stomach  with  air),  with  a  resulting 
sensation  of  tension  and  at  times  dyspeptic  asthma. 

Hysteric  or  neurasthenic  symptoms  are  associated. 

Aerophagia  (air  swallowing)  is  probably  the  cause.  The  upper 
part  of  the  abdomen  is  markedly  distended  and  tympanitic,  and  there 
is  interference  with  respiration.     As  a  rule,  there  is  no  belching. 

Diagnosis. — Organic  affections  of  the  stomach  must  be  excluded, 
in  which  the  gas  has  a  foul  odor  and  the  contents  ferment. 

Treatment. — Tonics  and  bromids  are  indicated.  Aspiration  of 
the  stomach  in  the  acute  attack,  so  as  to  give  exit  to  the  air,  is  the 
best  method.     It  may  be  necessary  to  repeat  it. 

Extract  physostigmatis,  gr.  ^  (0.008),  or  eserin,  gr.  jio  (0.00065), 
or  morphin,  gr.  I  (0.016),  or  tincture  of  belladonna,  1TLx  (0.59),  or 
extract  of  belladonna,  gr.  |  (0.016),  may  be  required. 

SECRETORY  NEUROSES 

The  secretory  function  of  the  stomach  is  undoubtedly  under  the 
direct  control  of  the  nervous  system.  For  example,  in  a  hungry 
dog  with  a  fistula  the  sight  of  meat  will  produce  gastric  secretion, 
and  in  the  case  of  a  man  with  impermeable  esophagus,  but  with  a 
gastric  fistula,  mastication  produced  gastric  secretion.  The  vagus 
has  been  demonstrated  to  be  the  secretory  nerve.  The  stomach 
itself,  however,  possesses  some  secretory  power,  since  after  section 
of  the  pneumo gastric  and  sympathetic  nerves,  secretion  will  occur  after 
the  application  of  an  irritant. 

Hyperchlorhydria,  gastrosuccorrhea  (hypersecretion),  and  achylia 
gastrica  may  all  be  functional  disorders  of  secretion,  and  have  been 
described  in  special  chapters. 


NERVOUS    AFFECTIONS   OF  THE   STOMACH  381 

Subacidity  (hyposecretion,  hypochylia  gastrica,  hypochlorhydria) 
may  be  of  nen^ous  origin,  and  must  be  differentiated  from  cases  occur- 
ring with  organic  disease  of  the  stomach,  especiahy  gastric  catarrh. 

Hydrochloric  acid,  strychnin,  massage,  and  electricity  are  of 
service  in  these  last  cases. 

In  the  subacid  cases  sudden  changes  in  the  gastric  findings 
(secretory)  are  in  favor  of  a  neurosis,  according  to  Hemmeter. 

Disorders  of  secretion  may  accompany  other  diseases,  such  as 
tabes,  or  spinal  lesions. 

Nervous  Dyspepsia  (Leube) 

{Synonym. — Neurasthenia  Gastrica.) 

Leube  originally  described  nervous  dyspepsia  as  a  disorder  of 
the  stomach,  characterized  by  a  variety  of  distressing  subjective 
symptoms  during  the  act  of  digestion,  but  in  which  it  was  normal 
as  regards  time  and  chemism.  In  effect,  he  originally  considered 
"nervous  dyspepsia"  as  a  neurosis  of  sensibility.  He  has  more 
recently  extended  his  definition  to  other  forms.  Strictly  speaking, 
nervous  dyspepsia  is  a  combined  gastric  neurosis  in  which  the  sensory 
disturbances  (subjective  symptoms)  are  the  most  prominent. 

It  may  be  combined  with  secretory  and  at  times  even  with  motor 
disturbances. 

Gastric  Juice. — The  findings  in  the  gastric  juice  are  not  char- 
acteristic. It  may  be  frequently  normal;  it  may  occasionally  be 
hyperacid,  more  frequently  diminished  acidity,  or  at  times  there  may 
be  variations  in  the  same  subject.  In  long  persistent  cases  atony 
may  be  present. 

Some  authors  refer  to  the  presence  of  enteroptosis  or  membranous 
colitis  with  neurasthenia  gastrica.  In  this  connection  it  is  evident 
that  frequently  the  diagnosis  of  "nervous  dyspepsia"  is  made,  when 
in  reality  gastroptosis  (enteroptosis)  is  the  basis  of  the  difficulty. 
"With  the  ptosis  of  the  viscera  we  have  sensory,  secretory,  and 
frequently  motor  disturbances  of  the  stomach,  associated  with 
nervous  symptoms,  but  the  correction  of  the  ptosis  will  cure  the 
condition. 

In  pure  nervous  dyspepsia  all  organic  lesions  of  Die  stomach  must 
be  excluded  and  also  ptosis  of  the  viscera.  The  stomach  must  occupy 
the  normal  position. 

Etiology. — Neurasthenia  gastrica  may  occasionally  appear  as 
an  independent  neurosis,  but  more  usually  with  nervous  symptoms, 
hysteria,  or  neurasthenia.  Grip,  pulmonary  disease,  anemia,  chlo- 
rosis, malaria,  or  debilitating  conditions  predispose  to  it,  as  do  also 
reflex  irritation  from  the  sexual  organs,  excessive  venery,  abuse  of 
alcohol,  or  tobacco. 

This  disease  occurs  more  frequently  in  men  than  in  women, 
especially  among  brokers  and  those  subject  to  worry  and  mental 


382  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

strain,  and  usually  at  the  prime  of  life  between  thirty  and  fifty, though 
it  may  be  present  at  other  periods. 

Symptoms. — The  patient  usually  complains  of  a  feeling  of  fulness 
or  pressure  after  eating,  or  even  of  shght  pain  or  belching,  loss  or 
irregularity  of  appetite,  a  sleepy  feehng,  or  even  weakness  or  dizzi- 
ness. The  tongue  is  usually  clean.  There  is  marked  mental  depres- 
sion, and  the  patients  are  nervous  and  anxious.  One  peculiarity  is 
that  the  quantity  and  qiiality  of  the  food  seem  to  make  'little  difference 
in  their  symptoms.  At  times  indigestible  food  can  be  taken  without 
discomfort,  while  at  other  times  digestible  food  may  produce  the 
symptoms.  Occasionally  the  pain  and  discomfort  are  present  when 
the  stomach  is  empty.  There  is  often  nausea  and  occasionally 
vomiting.  Thirst  is  variable.  There  is  usually  tension  or  fulness 
of  the  intestines  due  to  accumulation  of  gas,  which  is  passed  later 
per  rectum.  The  bowels,  as  a  rule,  are  constipated,  with  occasion- 
ally an  alternating  diarrhea.  The  movement  may  appear  in  narrow 
cylindroids  or  small  balls  in  some  cases. 

In  addition  to  the  feelings  of  depression,  insomnia,  palpitation, 
headache,  and  lassitude  may  be  present;  also  vertigo,  impotence, 
or  emissions. 

The  surroundings  and  general  mood  of  the  patient  have  a  marked 
influence  on  the  symptoms.  The  cases  are  often  extremely  dis- 
agreeable in  their  "home  life."  Circumscribed  points,  sensitive  to 
pressure,  have  been  described  as  diagnostic;  one  below  the  ensiform 
and  the  others  near  the  navel,  especially  to  the  left,  but  Ewald  has 
demonstrated  "nervous  dyspepsia"  in  which  no  such  points  could 
be  found. 

Course. — The  course  of  the  disease  is  slow  and  the  svmptoms 
vary;  sometimes  one  symptom  being  prominent;  at  another  time, 
another.  The  mood  of  the  patient  has  a  marked  influence  and  in 
good  company  he  may  forget  his  trouble.  They  generally  do  not 
sufifer  much  in  nutrition,  but  in  cases  with  insomnia  they  at  times 
lose  considerable  weight. 

Diagnosis. — The  presence  of  general  nerv^ous  s^^mptoms, 
especially  of  those  pointing  to  the  stomach,  without  the  presence  of 
organic  disease  of  the  organ;  the  fact  that  the  gastric  secretion  is  often 
found  to  be  normal,  though  at  times  hypochlorhydria  and  more 
rarely  a  mild  hyperchlorhydria,  and  that  we  frequentlv  obtain 
variable  gastric  analyses  in  the  same  patient;  that  there  is  lack  of 
proportion  between  the  gastric  findings  and  the  condition  of  the 
digestive  organs,  as  compared  with  the  severe  complaints  voiced  by 
the  patient;  that  the  character  of  the  food,  whether  digestible  or 
indigestible,  seems  to  make  no  difference  as  regards  increasing  or 
ameliorating  the  symptoms,  and,  finally,  that  change  of  scene  or 
the  mental  condition  of  the  patient  has  a  decided  influence  on  the 
condition — all  these  facts  point  to  neurasthenia  gastrica. 

Differential  Diagnosis. — The  chief  differences  are  as  follows: 


NERVOUS   AFFECTIONS   OF   THE   STOMACH  383 

Neurasthenia  Gastrica. — Character  of  the  food  makes  no  difference 
as  to  symptoms.  There  are  sudden  changes  in  the  patient's  condi- 
tion; well  for  a  few  days,  and  then  marked  symptoms;  nervous 
symptoms  marked.  Gastric  secretion  often  normal,  and  frequently 
variable  in  the  same  patient  at  different  times. 

Chronic  Gastritis. — Aggravated  by  errors  in  diet;  symptoms 
constant;  mucus  in  the  gastric  contents;  reduction  in  hydrochloric 
acid  is  marked  as  a  rule. 

Ulcer  of  the  Stomach. — Painful  area  in  the  epigastrium,  tender  on 
pressure;  hematemesis  or  occult  blood,  melena,  and  pain  is  increased 
markedly  after  ingestion  of  food.  The  character  of  the  food  influ- 
ences the  pain  markedly,  even  in  the  more  obscure  cases.  Pain 
remits  or  disappears. 

Cancer. — Age  of  patient;  tumor;  cachexia;  quality  and  quantity 
of  the  food  may  not  markedly  influence  the  pain;  gastric  analysis 
showing  absence  of  free  HCl,  lactic  acid,  and  Boas-Oppler  bacilli 
present ;  pain  continuous ;  progressive  emaciation. 

Treatment. — If  there  are  any  sexual  disorders  which  reflexly 
might  affect  the  nervous  condition,  these  should  be  treated;  sexual 
excesses  or  overindulgence  in  alcohol  or  tobacco  should  be  checked. 
Brokers  and  professional  men  who  have  mentally  overexerted  them- 
selves or  are  tired  with  the  worry  of  business  cares,  lead  an  irregular 
life,  or  who  are  engaged  too  actively  in  social  pursuits,  if  possible, 
should  have  a  change  of  scene.  Horseback  riding,  golf,  yachting, 
fishing,  shooting,  camp  life  for  a  few  weeks,  a  pleasure  trip,  all  give 
excellent  results.  A  short  ocean  trip  south  or  abroad  is  of  service. 
In  those  who  cannot  afford  these  methods,  the  lightening  of  business 
and  professional  cares  is  important. 

Hydrotherapy,  massage,  electricity,  especially  by  the  faradic 
current,  combined  with  out-of-door  life  and  proper  exercise,  mild 
gymnastics,  so  as  not  to  tire  the  patient,  are  of  value.  The  mental 
itnpression  created  by  the  physician  ^'.s"  important.  Static  electricity 
is  at  times  of  service.  General  faradization,  the  bare  feet  on  one 
electrode,  and  the  other  being  passed  over  the  body,  is  useful  (Rock- 
well). 

The  diet  should  be  abundant,  the  patient  avoiding  highly  seasoned 
food,  alcohol,  strong  coffee,  and  excessive  smoking. 

Stomachics  should  be  given  if  hydrochloric  acid  is  deficient,  such 
as  nux  vomica,  compound  tincture  of  cinchona,  dilute  hydrochloric 
acid,  etc. 

If  hyperchlorhydria,  then  the  alkalis  should  be  administered. 
The  patient  should  secure  the  proper  amount  of  sleep. 

Forced  feeding  and  the  Weir-Mitchell  rest  cure  are  necessary  in 
severe  cases.     Milk  and  raw  eggs  are  of  value  in  reduced  nutrition. 

Malbranc's  gastric  douche  has  been  recommended  in  some  cases, 
and  Einhorn  suggests  the  use  of  his  gastric  spray.  Personally  I  do 
not  employ  such  local  measures. 


384  DISEASES   OF  THE   STOMACH  AND   INTESTINES 

The  general  tone  of  the  patient  should  be  built  up  by  iron,  such  as 
peptomangan  (Gude's),  iron  pills,  iron  tropon,  arsenic,  and  strych- 
nin. Small  doses  of  nux  vomica  combined  with  compound  tincture 
of  cinchona  are  excellent  to  improve  the  appetite : 

I^.     Tr.  nucis  vomicse 3iij  (12.0) 

Comp.  tinct.  cinchona oss  (16.0) 

Aq.  destil q.  s.  §iv  (125.0). — ^M. 

Sig. — I  to  2  teaspoonfuls  t.  i.  d.  in  water  before  meals. 

Basic  orexin,  2  decigrams  (gr.  3)  t.  i.  d.,  has  also  been  recom- 
mended by  Einhorn  for  this  purpose. 

Sodium  or  ammonium  bromid,  gr.  v  to  x  (0.3-0.6)  two  or  three 
times  a  day,  lessens  the  nervousness. 

The  bowels  should  be  properly  regulated  by  cascara,  aloin  pills, 
phenolax,  etc.  Iron  springs,  such  as  Franzensbad,  or  salines,  as 
Kissengen  or  Wiesbaden,  are  of  service. 

The  carbonated  bath  (Nauheim,  Triton)  I  have  found — given 
every  other  day  at  home  for  a  course  of  12  baths  at  a  temperature 
of  95  °  to  98  °  F. — to  be  of  service  in  toning  up  the  circulation  and 
general  nervous  condition. 


CHAPTER  XVIII 

DYSPEPTIC  ASTHMA 

This  type  of  asthma,  due  to  digestive  disturbances,  was  first 
described  by  Henoch,^  later  by  Silberman,^  Oppler,^  Boas,*  Murdoch,^ 
and  Einhorn.®     Many  others  have  described  this  condition. 

The  symptoms  first  reported  by  Henoch  were  of  an  acute  type 
and,  according  to  his  behef,  were  the  result  of  reflex  action  starting 
from  the  stomach.  It  is  noteworthy  that  the  most  severe  symptom 
disappeared  when  the  patient  vomited.  In  his  cases  the  breathing 
was  rapid  and  shallow,  pulse  rapid  and  feeble,  and  at  times  so  rapid 
that  it  could  not  be  counted,  extremities  cool,  the  temperature  sub- 
normal, and  there  were  even  symptoms  of  collapse. 

In  all  cases  there  was  acute  dyspepsia  due  to  some  error  in  diet. 
The  region  of  the  stomach  was  usually  distended  and  painful.  The 
greatest  number  of  cases  were  observed  in  children.  Numerous 
explanations  have  been  given  for  this  condition,  and  a  variety  of 
experiments  have  been  performed.  Henoch  believes  it  to  be  due  to 
reflex  action,  starting  from  the  stomach  and  causing  a  vasomotor 
spasm;  while  Einhorn  suggests  reflex  irritation  of  the  vagus  fibers. 
In  view  of  the  fact  that  the  majority  of  cases  occur  after  dietetic 
error,  Riegel's  suggestion  of  auto-intoxication  as  a  factor  seems  to 
have  a  decided  hearing  on  the  subject. 

On  the  other  hand,  under  acute  dilatation  of  the  stomach  I 
referred  to  certain  peculiar  clinical  types,  in  one  of  which  many  of 
the  symptoms  resembled  angina  pectoris,  there  being  dyspnea  and 
rapid  and  feeble  heart  action,  and  in  some  attacks  loss  of  conscious- 
ness. These  attacks  followed  indiscretion  in  diet.  In  view  of  this 
fact  and  also  that  Henoch  describes  distention  of  the  stomach  as 
present  in  most  cases,  and  dietary  indiscretion  as  a  cause,  it  would 
seem  to  me  that  in  this  type  at  least  acute  gastric  dilatation  from 
auto-intoxication  is  a  factor.  Einhorn  describes  acute  cases  follow- 
ing excesses  in  eating,  drinking  or  smoking,  excitement,  or  from  no 
discoverable  cause.     Even  these  facts  do  not  mitigate  distention. 

The  second  group  which  he  classifies  are  more  of  a  chronic  type, 
appearing  after  meals,  or  after  overexertion,  or  without  apparent 

1  Berlin,  klin.  Wochenschr.,  1876,  No.  181. 

2  Ibid.,  1882,  No.  23. 

3  Allgem.  Med.  Central.  Zeit.,  1890,  No.  71,  p.  849. 
*  Arch.  f.  Verdauungskrank.,  Bd.  11,  1896,  p.  444. 
5  New  York  Med.  Journal,  Jan.  12,  1901. 

^  Jour.  Am.  Med.  Assoq.,  Feb.  i,  1902. 

25  385 


386  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

cause,  or  those  appearing  several  hours  after  meals  spontaneously, 
or  after  exertion. 

In  some  of  these  cases  a  small  amount  of  food  would  check  the 
attack.  The  last  type  would  seem  to  suggest  reflex  irritation  from 
hyperchlorhydria,  for  example,  which  when  relieved  would  stop  the 
asthma. 

Some  of  the  last  group  present,  in  some  cases,  symptoms  suggest- 
ive of  pseudo-angina  pectoris. 

Secretory  Functions. — Ach^-lia  gastrica  has  been  found  in  some 
patients  and  h3^perchlorh5^dria  in  others.  Treatment  of  these  con- 
ditions caused  subsequent  disappearance  of  the  attacks  of  asthma. 
In  achylia  the  coarse  particles  of  food,  Einhorn  believes,  might  cause 
reflex  irritation  of  the  vagus.  Asthma  dyspepticum  may  also  occur 
with  chronic  gastritis. 

On  the  other  hand,  these  attacks  have  occurred  in  patients  in 
whom  the  gastric  secretion  was  normal;  and  Boas  believes  that 
hyperesthesia  of  the  stomach  with  reflex  irritation  is  the  cause. 

Again,  in  my  case  of  acute  dilatation  with  some  of  the  attacks 
similar  to  angina,  the  gastric  secretion  was  normal;  but  dietary 
indiscretion  produced  gastric  distention  and  the  attack  noted.  It 
was  immediately  relieved  by  vomiting. 

Floating  liver  was  noted  by  Einhorn  in  5  cases,  and  this  together 
with  abdominal  ptosis  of  other  organs;  and  he  believes  that  the  pro- 
lapsed liver,  by  dragging  down  the  diaphragm,  may  be  a  cause  of 
this  type  of  asthma.  In  my  own  opinion  ptoses  of  the  viscera  have 
an  influence  on  the  secretory  conditions  in  the  gastro-intestinal 
tract,  and  only  to  this  degree  predispose  to  dyspeptic  asthma. 
Probably  these  various  factors  to  which  I  have  referred  may  have 
a  bearing  in  different  cases. 

Treatment. — Disorders  of  the  gastric  secretion  must  be  appro- 
priately corrected,  and  ptosis  of  the  viscera  supported  by  Rose's 
adhesive  belt. 

Excesses  in  the  use  of  alcohol  and  tobacco  must  be  corrected, 
mental  worry  and  strain  be  avoided,  and  the  mode  of  life  must  be 
regulated. 

All  indigestible  food  must  be  avoided  and  diet  suitable  to  each 
case  must  be  instituted.  By  this  means  many  cases  will  be  relieved 
and  often  cured. 

In  acute  cases  with  distention  of  the  stomach  lavage  is  indicated, 
also  calomel,  gr.  5  (0.3),  followed  by  a  saline  cathartic.  Catharsis 
is  also  indicated  in  cases  following  excesses  in  eating  or  drinking. 


CHAPTER  XIX 

THE  STOMACH  FUNCTIONS  IN  DISEASES  OF  OTHER 

ORGANS 

Unquestionably  there  are  few  diseases,  either  constitutional  or 
local,  which  are  not  attended  to  a  greater  or  lesser  degree  by  some 
disturbance  of  the  digestive  organs.  These  are  dependent  on  the 
general  disturbance  of  the  organism  and  are  appropriately  discussed 
under  the  symptoms  of  each  disease. 

In  the  present  chapter  I  shall  only  briefly  refer  to  those  diseases 
in  which  disturbances  of  the  gastric  functions  are  particularly 
conspicuous. 

FUNCTIONS  OF  THE  STOMACH  IN  ACUTE  FEBRILE  DISEASES 

Numerous  investigations  have  been  carried  out  both  on  animals 
and  men,  in  some  of  which  at  least  accurate  quantitative  gastric 
analyses  were  performed.  Riegel  concludes  that  we  are  probably 
justified  in  stating  that  in  acute  febrile  infectious  diseases  the  pro- 
duction of  hydrochloric  acid  was  more  frequently  reduced  than 
normal,  and  the  secretion  of  pepsin  is,  as  a  rule,  unchanged.  Prob- 
ably the  fever  is  responsible  and  the  condition  is  temporary.  Von 
Noorden^  showed  that  hydrochloric  acid  reaction  can  be  obtained 
in  fever  cases  if  pepper  and  salt  are  administered  with  the  food. 

Some  interesting  researches  have  been  carried  out  in  numerous 
cases  of  typhoid  and  pneumonia.  During  the  high  temperature  of 
these  diseases  there  was  a  marked  diminution,  and  in  some  cases 
an  absence  of  hydrochloric  acid.  During  defervescence  an  increase 
of  the  secretion  was  noted.  During  high  tempratures  pure  milk  was 
found  in  the  stomach  in  a  curdled  condition  several  hours  after  the 
normal  time  for  evacuation,  and  in  one  case,  on  autops}^  the  stomach 
was  found  filled  with  the  curdled  milk  of  previous  feedings,  thus 
demonstrating  a  diminution  of  the  motor  function.  Water  alone 
was-  then  administered  at  this  period.  During  lower  temperatures 
foods  freely  soluble  in  water,  such  as  broths  and  gruels,  were  found 
best.  There  was  less  fermentation  and  distention  under  this  method 
of  feeding  and  the  stomach  more  readily  emptied  itself. 

In  my  own  experience^  I  can  confirm  the  fact  that  during  the 

high  temperature  of  typhoid  the  free  hydrochloric  acid  diminished, 

often  markedlv,  and  the  motor  function  is  not  as  active.     It  has  also 

been   found  that  biliary  secretion  is  disturbed   during  high   fever. 

Stolmkow   noted  disturbances  in  the    pancreatic    secretion   during 

high  temperature. 

1  Lehrbuch  der  Pathologic  des  Stoffwechseis,  1893. 
^  American  Medicine,  May,  1909. 

387 


388  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

CHRONIC  FEBRILE  CONDITIONS 

Observers  vary  considerably  in  their  findings  in  the  gastric 
secretion  in  these  cases,  some  noting  no  changes  whatever.  In 
my  own  experience  the  temperature,  as  a  rule,  caused  disturbance 
in  the  secretory  function  of  the  stomach,  lessening  the  HCl  pro- 
duction. The  type  of  disease,  the  physical  condition,  the  personal 
equation  of  the  patient,  and,  most  important,  the  time  at  which  the 
analysis  is  made,  all  have  a  hearing.  I  shall  refer  shortly  to  the  work 
of  Hildebrandt  on  this  subject,  under  Tuberculosis.  The  power  of 
absorption  seems  to  be  impaired  in  fever  (Sticker).^ 

CONDITION  OF  THE  STOMACH  IN  PULMONARY  TUBERCULOSIS 

Phthisis  quite  frequently  begins  with  dietetic  disturbances,  such 
as  heart-burn,  belching,  pressure,  nausea,  loss  of  appetite,  constipa- 
tion alternating  with  diarrhea,  and  even  vomiting,  with  the  lung 
symptoms  so  slight  as  to  be  at  first  overlooked.  It  has  been  called 
pre  tubercular  dyspepsia.  In  the  later  stages  we  may  have  the 
dyspeptic  symptoms  quite  marked. 

Hildebrandt"  found  the  following  results:  The  cases  in  which 
free  hydrochloric  acid  was  present  usually  had  no  fever,  while  those 
in  whom  it  was  absent  suffered  from  continuous  fever.  When  it 
was  absent  at  one  part  of  the  day,  it  was  when  the  temperature  was 
high ;  and  when  present  at  another  part,  it  was  when  the  temperature 
was  low.  The  temperature,  therefore,  exercised  an  influence. 
These  findings  were  in  advanced  cases.  Klemperer^  studied  lo 
cases  in  the  initial  stage,  3  in  the  advanced,  and  i  in  the  moderate. 

In  the  beginning  the  secretory  power  of  the  stomach  was  usually 
increased,  often  normal,  and  rarely  reduced.  In  the  terminal  stages, 
always  greatly  reduced.  Motor  reduction  slight  in  the  initial  stages, 
reduced  in  later  stages. 

Brieger*  analyzed  64  cases:  31  advanced,  with  continuous  fever ; 
37  moderate,  with  more  or  less  fever;  6  incipient  cases,  with  no  fever. 
Gastric  secretion  normal  in  16  per  cent,  of  advanced  cases,  and  in 
the  others  insufficiency  of  varying  degrees;  in  9.6  per  cent,  absence 
of  free  hydrochloric  acid.  In  moderate  cases,  33^  per  cent,  normal, 
and  in  all  others  perversion;  and  in  6.6  per  cent,  normal  secretion 
absent.  In  the  initial  cases,  normal  secretion  and  perversion  were 
equally  divided. 

Einhorn'  has  shown  in  analysis  of  1 5  cases  that  the  appetite  does 
not  seem  to  correspond,  as  would  be  expected,  to  the  gastric  findings; 
and  also  that  frequently  the  subjective  symptoms  do  not  harmonize 
with  the  objective  findings. 

1  Deutsch.  med.  Wochenschr.,  1889,  No.  15. 

2  Berlin,  klin.  Wochenschr.,  i88s. 

3  Ibid.,  1889,  No.  2. 

^Deutsch.  med.  Wochenschr.,  1889,  No.  14. 
^Loc.  cit. 


THE    STOMACH    FUNCTIONS    IN    DISEASES    OF    OTHER   ORGANS      389 

Treatment.-^The  main  indication  is  to  improve  the  resisting 
power  of  the  patient  against  the  primary  disease. 

Forced  feeding,  especiall}^  by  Russell's  method,  rest  in  bed,  and 
fresh  air,  with  milk  and  vegetable  juices,  I  believe  the  best  treat- 
ment for  the  tuberculosis.  I  have  seen  a  gain  of  15  to  25  pounds  in 
each  case  by  his  methods  at  Ward's  Island  in  12  cases  in  eight  weeks. 

The  heart  and  kidneys  must  functionate  properly  for  success  with 
his  method.  Functional  disturbances  of  the  stomach  should  be  treated. 
Tuberculous  ulcer  of  the  stomach  is  occasionally  met  with  in  connec- 
tion with  tuberculosis  of  the  other  organs. 

CHLOROSIS  AND  ANEMIA 

Among  the  gastric  symptoms  in  these  conditions  are  found 
gastralgia,  anorexia,  hyperesthesia  of  the  stomach,  hyperchlor- 
hydria,  and  chronic  atony. 

These  symptoms  appear  more  frequently  after  eating  than  on  an 
empty  stomach,  and  occur,  as  a  rule,  in  attacks  at  irregular  intervals. 
There  are  often  perversions  of  appetite.  The  atony,  if  neglected, 
may  progress  to  chronic  atonic  ectasia. 

In  chlorosis  (primary  anemia)  the  hydrochloric  acid  secretion  is, 
as  a  rule,  increased. 

In  anemia  (secondary),  on  the  other  hand,  depending  on  the 
causative  disease  we  may  find  variable  results;  hydrochloric  acid 
decreased,  normal,  or  (more  rarely)  increased. 

In  this  I  agree  with  Riegel. 

The  relation  between  achylia  gastrica  and  pernicious  anemia  has 
already  been  described.  The  relation  of  intestinal  putrefaction  to 
this  disease  is  described  later. 

Many  of  the  derangements  belong  to  the  neuroses  and  are  depend- 
ent on  the  condition  of  the  blood.  The  administration  of  iron  is 
chiefly  indicated,  with  the  additional  correction  of  the  functional 
disturbance  if  such  be  present. 

HEART  LESIONS 

^  In  general  we  may  say  that  while  compensation  is  present,  in 
many  cases  the  stomach  functions  are  normal  or  nearly  so;  with 
imperfect  or  failing  compensation,  with  resulting  stasis  and  hyper- 
emia in  the  gastric  mucous  membrane,  I  have  noted  diminution  in 
the  amount  of  free  hydrochloric  acid  with  accompanying  digestive 
disturbances,  belching,  pressure,  anorexia,  and  at  times  nausea  and 
even  vomiting,  with  sick  headache.  These  conditions  improved  after 
treatment  was  directed  to  the  circulation.  In  severe  cases  free  HCl 
may  be  absent.  In  one  case  with  poor  compensation  and  frequent 
gastric  attacks,  a  course  of  treatment  at  Nauheim  produced  excellent 
results. 

Symptoms  simulating  heart  lesions  may  be  produced  by  gastric 
disorders,  thus :  Ulcer,  chronic  ectasy,  and  chronic  gastritis  may  pro- 


390  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

duce  bradycardia   or  arhythmia;   or  tachycardia   may  occur  with 
chronic  gastritis,  in  nervous  gastric  disorders,  or  with  atony. 

Tachycardia  with  acute  dilatation  of  the  stomach,  especially 
with  existing  heart  lesions,  the  author  has  described  in  the  chapter 
on  Acute  Ectasy. 

DISEASES  OF  THE  LIVER 

Diseases  of  the  liver  are  generally  accompanied  by  gastric  symp- 
toms; with  cirrhosis  and  the  resulting  circulatory  disturbances  of 
the  viscera  the  gastric  secretion  (free  hydrochloric  acid)  is  more 
frequently  diminished.     The  findings  in  other  liver  disturbances  are 

not  constant. 

ANEURYSM 

In  a  case  of  aneurysm  of  the  celiac  axis,  referred  to  under  Cancer, 
free  hydrochloric  acid  was  absent,  lactic  acid  present,  and  the  stomach 
dilated.  Circulatory  disturbances  were  responsible  for  the  gastric 
findings  and  pressure  for  the  dilatation  of  the  stomach. 

DISEASES  OF  THE  KIDNEYS 

Gastric  disturbances  are  frequent  in  nephritis,  and  nausea  and 
vomiting  may  be  the  first  symptoms.  In  fact,  Osier  has  reported 
death  with  these  symptoms,  and  nephritis  may  be  unsuspected  until 
autopsy.  The  excretion  of  urea  through  the  gastric  mucous  mem- 
brane or  cerebral  irritation  from  the  poison  are  responsible  for  the 
vomiting.  Variable  conditions  of  the  gastric  secretion  have  been 
reported  by  various  observers. 

Biernaki^  has  studied  25  cases  of  nephritis,  both  acute  and 
interstitial,  and  found  in  general  the  gastric  secretion  was  diminished, 
and  also  that  the  quantity  of  free  hydrochloric  acid  was  reduced  in 
proportion  to  the  extent  of  the  edema,  the  excretion  of  albumin, 
and  the  reduction  in  the  quantity  of  urine  excreted.  Pepsin  was 
reduced  and  the  motor  function  was  increased.  Free  hydrochloric 
acid  was  present  in  the  mild  cases  in  large  or  small  quantities. 

Einhorn  has  observed  achylia  gastrica  in  a  case  of  renal  calculus, 
which  disappeared  after  operation,  and  A.  A.  Jones^  has  found  achylia 
gastrica  among  patients  with  kidney  disturbances. 

DIABETES 

Variable  results  have  been  secured.  Atrophy  of  the  gastric 
mucosa  has  been  found  in  a  few  cases.     The  motor  power  was  good. 

Rosenstein^  reports  normal  secretion  in  4  cases  and  abnormal  in 
6,  while  Gans*  found  6  normal  and  4  negative.  The  findings  are 
not  constant,  and  both  normial  and  abnormal  conditions  of  the 
secretion  have  been  observed. 

1  Berlin,  klin.  Wochenschr.,  1891,  Nos.  25  and  26. 
"  New  York  Medical  Journal,  January  19,  1895. 
^Berlin,  klin.  Wochenschr.,  1890,  No.  15. 
*  IX  Congress  f.  innere  Medicin,  1890,  Wiesbaden. 


THE    STOMACH    FUNCTIONS    IN    DISEASES    OF    OTHER    ORGANS      39 1 

.      ARTHRITIS  DEFORMANS 

In  I  case^  I  found  hyperchlorhydria  marked ;  and  Einhorn  reports 

I  case  of  achylia. 

GOUT 

In  2  cases  Einhorn  reports  achylia,  and  in  several  mild  cases 
hyperchlorhydria. 

Grip. — Gastric  disturbances  are  reported  by  Kaufmann  in  grip. 

MALARIA 

Gastralgia  may  occur  as  a  substitute  for  the  malarial  paroxysms 
and  has  already  been  described,  or  vomiting  may  be  present,  asso- 
ciated with  malarial  symptoms.  There  are  no  characteristic  features 
of  the  gastric  secretion,  but  in  the  latter  cases  free  hydrochloric  acid 
may  be  diminished. 

Arteriosclerosis. — General  arteriosclerosis  may  affect  the  gastric 
vessels  and  produce  disturbances.  Harlow  Brooks  refers  to  arterio- 
sclerosis occurring  chiefly  in  the  abdominal  vessels.  The  possibility 
of  this  latter  condition  should  be  considered  (see  Visceral  Arterio- 
sclerosis). 

DISEASES  OF  THE  SKIN 

Eczema. — Various  systemic  conditions  probably  have  a  bearing, 
and  in  some  few  cases  correction  of  the  digestive  disturbances  seem 
to  have  an  influence  in  improving  the  condition.  In  one  case  I 
found  hyperchlorhydria,  and  in  another  deficient  hydrochloric  acid. 

Hyde^  believes  that  gout,  dyspepsia,  constipation,  and  scrofula 
have  a  decided  influence. 

Acne  Simplex  and  Acne  Rosacea. — ^These  are  associated  at 
times  with  gastric  disturbances.  Einhorn  reports  2  cases  of  acne 
rosacea  in  whom  chronic  continuous  gastrosuccorrhea  was  found. 
The  correction  of  the  latter  benefited  the  skin  affection. 

Psoriasis. — The  treatment  of  gastric  disorders  in  this  affection 
does  not  seem  to  benefit  the  lesion,  according  to  Einhorn. 

Urticaria  and  Erythema. — Some  persons  have  an  idiosyncrasy 
to  lobsters,  crabs,  strawberries,  etc.,  and  develop  therefrom  poisonous 
substances  which  produce  these  eruptions,  associated  at  times  with 
acute  gastric  symptoms.  These  conditions  seem  to  be  due  to  auto- 
intoxication. Combe  ("  Intestinal  Auto-intoxication")  believes  that 
acne,  the  seborrheic  eczemas,  urticaria,  pruritus,  strophulus  infantum, 
and  furunculosis  to  be  chiefly  due  to  intestinal  auto-intoxication. 
He  advises  fresh  brewers'  yeast,  oj  (4.0)  t.  i.  d.,  before  meals  for 
these  conditions.  Duncan  Bulkley  believes  that  cutaneous  lesions 
are  in  some  cases  produced  through  cutaneous  elimination  of  toxic 
substances.     The  author  holds  that  the  entire  gastro-intestinal  tract 

1  The  relation  of  intestinal  putrefaction  to  arthritis  deformans  is  described 
later.  * 

2  Twentieth  Century  Practice,  vol.  v. 


392  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

should  receive  attention.  Thorough  catharsis  should  be  carried  out. 
These  foods  should  thereafter  be  avoided. 

Pemphigus  of  the  Mouth. — Einhorn  has  noted  3  cases  in  which 
there  was  hyperchlorhydria  or  neurasthenia  gastrica,  and  in  2  cases 
improvement  resulted  from  treating  the  gastric  symptoms. 

In  general,  we  may  say  that  considerable  investigation  is  still 
necessary  to  definitely  determine  the  relations  of  gastric  disturbances 
to  skin  diseases. 

SYPHILIS   OF  THE  STOMACH 

Gastric  symptoms  quite  frequently  occur  in  the  secondary  and 
tertiary  stages  of  syphilis.  In  the  secondary  stage  they  may  often  be 
attributed  to  fever  (the  constitutional  condition) ;  while  in  the  ter- 
tiary stage  there  are  anatomic  changes  in  the  stomach  itself. 

Fenwick^  believes  that  syphilis  may  affect  the  stomach  in  three 
ways:  By  the  formation  of  gummata,  by  producing  endarteritis, 
and  by  a  chronic  inflammation  of  the  mucous  membrane.  The 
symptoms  arising  subside  under  antisyphilitic  treatment. 

Flexner"  holds  that  syphilitic  gastric  ulcer  is  not  rare,  while 
Dieulafoy^  notes  various  lesions,  such  as  hemorrhagic  erosions, 
ecchymoses,  gummata,  infiltration  of  the  submucosa  and  circum- 
scribed gummatous  ulceration,  and  cicatrices  of  the  latter.  Pain, 
vomiting,  hematemesis,  and  melena  occur. 

RiegeP  reports  12  cases  in  which  they  complained  of  gas,  nausea, 
distress  after  eating  and  gastralgia,  which  responded  promptly  to 
antisyphilitic  remedies. 

Death  has  resulted  from  perforation  of  a  broken-down  gumma. 

All  doubtful  cases  should  be  examined  for  signs  of  previous 
syphilitic  infection,^  for  active  syphilitic  manifestation;  also  as  to 
the  history,  and  should  be  tested  by  specific  treatment.  Of  course, 
many  patients  may  have  digestive  disturbances  without  any  con- 
nection with  the  old  luetic  condition. 

Hemmeter®  has  described  syphilis  of  the  stomach. 

Einhorn^  gives  the  following  classification  and  describes  cases: 

(i)  Gastric  ulcer  of  syphiHtic  origin. 

(2)  Syphilitic  tumor  of  the  stomach. 

(3)  Syphilitic  stenosis  of  the  pylorus. 
To  this  I  shall  add  a  fourth  type: 

(4)  Syphilitic  cirrhosis  of  the  stomach. 

1  London  Lancet,  Sept.  20,  1901. 

2  Am.  Jour.  Med.  Sciences,  Oct.,  1898.' 
^Gaz.  heb.  de  Med.,  1902. 

*  Diseases  of  the  Stomach. 

5  The  test  for  Wassermann's  reaction  is  important,  both  as  confirmatory  and 
for  the  diagnosis  of  doubtful  cases. 

6  Diseases  of  the  Stomach,  p.  556,  1897. 
^  Ibid.,  p.  534,  igo6. 


THE    STOMACH    FUNCTIONS    IN    DISEASES    OF    OTHER   ORGANS      393 

(I)  Gastric  Ulcer  (Syphilitic) 

A  number  of  cases  have  been  reported  in  which  the  usual  treat- 
ment for  ulcer  failed,  and  which  made  complete  recovery  under 
specific  treatment. 

(2)  Syphilitic  Tumor  of  the  Stomach 

This  condition  is  excessively  rare.  Einhorn  has  reported  2  cases, 
and  refers  to  the  fact  that  they  may  run  their  course  like  carcinoma. 
I  referred  to  a  case  in  this  volume  under  Differential  Diagnosis  in 
Carcinoma  of  the  Stomach.  In  this  patient  the  gastric  analysis 
showed  absence  of  hydrochloric  acid  and  lactic  acid  abundant.  The 
patient  had  lost  77  pounds  in  eight  months  and  was  vomiting  con- 
tinuously. The  stomach  was  dilated  to  below  the  umbilicus,  and 
though  he  had  been  on  specific  treatment  for  a  time  before  I  saw 
him,  the  pyloric  obstruction  was  so  marked  that  drainage  of  the 
stomach  was  necessary  to  preserve  life.  Palpation  gave  a  sense  of 
resistance  at  pylorus. 

A  rapid  laparotomy  at  the  Red  Cross  Hospital  disclosed  a 
gummatous  tumor  at  the  posterior  wall  of  the  pylorus,  nearly 
blocking  it.  Gastro-enterostomy  was  performed  and  specific  treat- 
ment pushed.  There  was  no  more  vomiting  and  the  case  has 
steadily  improved. 

(3)  Syphilitic  Pyloric  Stenosis 

Einhorn  reports  a  case  of  pyloric  stenosis  cured  by  antisyphilitic 
treatment.  In  most  of  these  cases,  however,  gastro-enterostomy 
is  required  in  addition  to  the  antiluetic  treatment. 

(4)  Syphilitic  Cirrhosis  of  the  Stomach 

This  case  has  also  been  referred  to  under  Cancer.  The  stomach 
was  small,  hard,  and  contracted,  and  on  palpation  felt  like  a  cir- 
rhotic carcinoma,  involving  the  entire  stomach.  The  patient  was  an 
elderly  man,  had  lost  considerable  weight,  and  was  suffering  from 
gastric  symptoms. 

Examination  demonstrated  cirrhosis  of  the  liver  and  evidences 
of  old  syphilis.     Deficient  HCl,  or  achylia,  occurs  in  this  type. 

These  facts  show  that  the  syphilitic  history,  or  evidences  of  the 
same,  should  be  investigated  carefully  in  gastric  affections. 

Treatment  should  be  for  syphilis.  Appropriate  remedies  may 
be  given  in  addition  for  special  symptoms,  or  secretory  or  motor 
disturbances. 


PART  III 
DISEASES  OF  THE  INTESTINES 


CHAPTER  XX 

METHODS  OF  EXAMINATION  OF  THE  INTESTINES; 
EXAMINATION  OF  THE  FECES;  MECHANICAL  PRO- 
CEDURES. 

Special  Interrogation. — We  presuppose  that  the  method  of 
interrogation  of  the  patient,  as  described  in  Part  I,  has  been  carried 
out.  Disease  of  the  stomach  may  produce  secondary  intestinal 
symptoms,  aijd  hence  the  condition  of  this  organ  must  be  inquired 
into,  and  in  many  cases  the  functions  examined. 

Inquire,  furthermore,  whether  abdominal  pains  are  present,  and 
also  their  position.  In  the  right  iliac  fossa  they  suggest  appendicitis 
or  catarrh  of  the  cecum;  in  the  left  iliac  fossa,  disturbances  of  the 
descending  colon  or  sigmoid. 

With  rectal  pain,  inflammation  in  that  region  is  probable,  while 
pains  near  the  navel  usually  originate  in  the  small  intestine.  Pains 
of  short  duration  and  sharp  in  character  are  generally  due  to  colic, 
and  are  followed  and  relieved  by  the  passage  of  flatus  or  feces. 
They  often  shift  from  one  region  to  another.  Pains  of  long  duration 
are  usually  from  some  organic  lesion,  such  as  ulcer  or  from  some 
affection  of  the  sensory  nerves. 

Abnormal  sensations,  such  as  feelings  of  heat  or  cold,  may  be 
experienced  over  different  regions  of  the  abdomen. 

Tenesmus  is  present  in  dysentery  and  in  many  rectal  affections. 
The  time  of  the  pain,  whether  immediately  after  meals  or  later,  or 
during  the  night  or  in  the  early  morning,  is  important. 

The  stool  should  be  investigated — whether  constipation,  diarrhea, 
or  alternating  conditions  exist,  the  number  of  movements,  time  of 
appearance,  odor,  color,  and  characteristics,  as  to  whether  mucus, 
blood,  bile,  pus,  or  undigested  food  are  present. 

Do  climatic  changes  or  mental  excitement  influence  the  bowel 
action,  or  are  headache,  dizziness,  or  exhaustion  associated  with 
the  movements?  Is  there  distention  of  the  abdomen  with  gas, 
localized  or  general?  When  does  it  appear?  Is  rumbling  (are 
borborygmi)  present?  Do  belching  of  wind  or  passage  of  gas  from 
the  bowel  occur,  and  does  this  give  relief? 

Total  absence  of  flatus  is  important.  Occurring  with  obstinate 
constipation,  it  would  then  suggest  obstruction. 

394 


PHYSICAL  EXAMINATION   OF  THE)   INTESTINES  395 

Continuous  vomiting  associated  with  intestinal  symptoms 
suggests  obstruction.  With  acute  symptoms  the  temperature  should 
be  taken  immediately. 

PHYSICAL  EXAMINATION  OF  THE  INTESTINES 

The  reader  is  referred  to  Chapter  IV  for  general  methods. 

Inspection. — The  retracted  or  trough-shaped  abdomen  occurs 
in  stricture  of  the  esophagus  or  cardia,  basilar  meningitis,  lead- 
poisoning,  and  with  long-continued  inanition.  The  peculiar  contour 
of  enteroptosis  has  been  described — the  concave  epigastrium,  sulcus 
between  the  recti  above  the  umbilicus,  and  the  pot-belly  below. 

On  distention  of  the  normal  colon  with  gas  (CO2),  the  ascending 
and  descending  portions  are  seen  as  elongated  swellings  in  the 
lateral  regions,  and  the  transverse  colon  at  or  just  above  the  um- 
biHcus. 

Protrusion  oi  the  abdomen  may.ue  over  a  definite  area  or  over 
the  entire  surface.  It  may  assume  the  shape  of  a  rounded  hemi- 
sphere, or  oval,  slightly  flattened,  especially  in  atonic  conditions  of 
the  intestines  and  in  hysteria.  Marked  uniform  distention  with 
tense  abdominal  walls,  absence  of  respiratory  abdominal  movements 
and  increased  thoracic  respiration  are  present  in  peritonitis.  There 
may  be  a  general  bloating  with  atony,  but  there  is  not  the  marked 
tension  of  the  abdominal  walls,  and  the  other  symptoms  are  absent. 

With  ascites  the  abdomen  is  evenly  protuberant  above,  with  the 
center  somewhat  flattened,  while  the  lateral  and  dependent  parts 
bulge  somewhat  in  the  recumbent  position;  change  of  posture  alters 
the  shape  of  the  abdomen.     This  applies  to  the  milder  types. 

With  marked  distention,  as  with  meteorism,  the  enlargement  is 
uniform.  There  is  no  bulging  in  any  special  location,  except  that 
the  anterior  portion  is  more  prominent  and  change  of  position  has 
no  effect.     Palpation  aids  under  these  conditions. 

There  may  be  protrusion  of  the  abdomen  in  cases  of  neoplasm, 
in  fecal  accumulation,  and  occasionally  in  abscess,  as  of  the  appendix, 
from  diverticulitis  or  other  intra-abdominal  suppuration. 

Hernial  protrusions  at  the  umbilicus  or  in  the  inguinal  regions 
may  be  observed. 

In  patients  with  thin  abdominal  walls,  small  sausage-shaped 
protrusions  are  occasionally  visible,  which  change  their  shape  and 
position.  This  is  due  to  peristalsis  of  the  small  intestine,  occurs  with 
no  pain,  and  denotes  no  morbid  condition. 

Similar  waves  may  appear  periodically  and  annoy  the  patient 
when  caused  by  nervous -influences. 

There  are  sometimes  violent  contractions  (peristaltic  unrest)  of 
the  small  intestine  visible,  caused  by  stenosis  or  obstruction.  If  it 
is  near  the  ileocecal  valve,  the  swollen  and  moving  coils  of  intestine 
lie  one  above  the  other  in  the  central  part  of  the  abdomen  (ladder 
pattern).     Intense  pain  accompanies  these  movements. 


396  DISEASES   OF  THE  STOMACH  AND  INTESTINES 

Marked  distention  may  be  visible  in  the  course  of  the  colon  (in 
the  circumference  of  the  abdomen),  and  if  associated  with  visible 
peristaltic  contractions  of  the  large  intestine,  passing  along  it  from 
right  to  left,  it  is  diagnostic  of  partial  or  total  obstruction  of  the 
large  bowel. 

In  some  cases  a  recurring  protuberance  is  noted,  disappearing 
with  a  loud  sound.     This  is  probabl}^  near  the  point  of  stenosis. 

INSPECTION    OF    THE    RECTUM— PROCTOSCOPY    AND    SIGMOID- 
OSCOPY 

The  anus  can  be  inspected  by  having  the  patient  lie  on  his  side 
with  thighs  and  knees  flexed,  and  his  back  toward  the  examiner. 


Fig.  162. — Kelly's  short  rectal  speculum. 

The  buttocks  should  be  held  apart  with  the  hands.     Hemorrhoids, 
fissures,  and  fistulse  may  be  discovered. 

For  inspection  of  the  rectum  the  introduction  of  a  speculum 
(proctoscope)  is  necessary. 


Fig.  163. — Kelly's  standard  rectal  speculum. 

Proctoscopy. — Various  instruments  have  been  devised,  notably 
those  of  Howard  Kelly,  Sims,  Kelsey,  Gant,  and  J.  P.  Tuttle  (Figs. 
162-170). 


INSPECTION    OF   RECTUM — PROCTOSCOPY   AND    SIGMOIDOSCOPY    397 

The  bowels  should  preferably  be  thoroughly  evacuated  before 
the  examination.  If  the  region  is  sensitive,  a  few  drops  of  a  2  to  5 
per  cent,  cocain  solution  can  be  injected  inside  and  along  the  sphinc- 


Fig.  164. — Kelly's  proctoscope  (}  actual  size). 

ters  with  a  narrow-pointed  rubber  syringe.  A  suppository  containing 
opium,  gr.  j  (0.065),  with  extract  of  belladonna,  gr.  ^  (0.022),  or 
cocain,  gr.  ■§•  (0.008),  can  be  substituted. 


Fig.  165. — Kelly's  sigmoid  speculum. 

Tuttle's  pneumatic  proctoscope  is  a  valuable  instrument.     There 
is  an  electric  lamp  at  the  end  of  the  inspection  tube  and  an  arrange- 


Fig.  166. — Sims'  rectal  speculum. 

ment  for  inflation  of  the  rectum,  so  that  it  can  be  distended  with 
air  at  the  time  of  examination. 

With  other  specula,  a  head-mirror  with  electric-light  attachment 
is  most  convenient,  though  an  ordinary  light  can  be  arranged.    The 


398 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


patient  lies  on  the  side,  with ■  thighs  and  knees  flexed,  with  back 
toward  examiner,  or  the  legs  can  be  elevated  on  a  crutch,  or  in  some 
cases  the  knee-elbow  position  can  be  assumed.  The  external  sphinc- 
ter as  well  as  the  speculum  should  be  lubricated  with  sweet  oil  or 
vaselin,  to  render  introduction  more  easy. 


Fig.  167. — Kelsey's  speculum. 

A  long  speculum  (sigmoidoscope)  may  be  required  for  examina- 
tion of  the  sigmoid. 

Palpation.— The  technic  of  simple  and  reinforced  palpation  has 
been  described  in  Chapter  IV. 


Fig.  168. — Gant's  examining  speculum. 

The  cecum,  parts  of  the  ascending  and  descending  colon,  the 
transverse  colon,  and  the  sigmoid  flexure  are  often  accessible  to 
palpation,  but  not  as  readily  so  in  obese  or  in  muscular  subjects. 
Fecal  accumulation,  tumors,  thickening  of  the  gut,  or  purulent  col- 
lections connected  with  the  intestine  can  often  thus  be  recognized. 


INSPECTION    OF    RECTUM — PROCTOSCOPY   AND    SIGMOIDOSCOPY    399 

An  uneven   protuberant  surface  is  characteristic  of  malignant 
growth,  while  an  even  surface  is  more  often  found  in  benignant 


Fig.  169. — Gant's  hinged  speculum. 

neoplasm  or  intussusception.     Volvulus  occurs  usually  in  the  sig- 
moid.    A  fecal  accumulation  will,  as  a  rule,  "pit"  on  pressure  (give  a 


Fig.  170. — A,  Tuttle's  pneumatic  proctosigmoidoscope.  Two  lengths — rectal 
4  inches,  sigmoid  10  inches — with  window  attachment  to  make  instrument  air- 
tight for  bowel  inflation;  B,  Tuttle's  sigmoidoscope  with  Mercier  curve. 


doughy  feel).  Hard  scybalae  occasionally  feel  like  marbles  under  the 
fingers,  but  can  be  moved  or  slightly  indented.  Sometimes  when 
raising  the  fingers  from  palpating,  there  may  be  a  crepitating  or 


400  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

sticky  sensation,  or  the  intestinal  wall  can  be  felt  to  slip  off  from 
the  fecal  mass.     This  symptom  was  first  described  by  Gersuny.^ 

Gurgling  occurs  on  palpation  in  typhoid  in  the  right  iliac  fossa, 
but  is  not  diagnostic. 

Tenderness  or  pain  on  pressure  can  be  readily  determined  by 
palpation,  and  are  suggestive  of  inflammatory  processes  or  ulceration. 
There  may  be  the  general  tenderness  of  acute  intestinal  inflammation 
or  the  acute  pain  and  tenderness  of  peritonitis,  either  localized  or 
general. 

Circumscribed  pain  on  pressure  may  be  present  at  McBurney's 
point  ( 1 2^  to  2  inches  to  the  inner  side  of  the  anterior  superior  spine  of 
the  right  ileum)  on  a  line  drawn  from  this  process  to  the  umbilicus. 

With  ulceration  of  the  bowels  there  may  be  circumscribed  areas 
very  sensitive  to  pressure;  with  hysteric  manifestations  there  are 
often  sensitive  spots  complained  of  in  the  abdomen,  as  for  example, 
in  mucous  colic.  By  palpating  simultaneously  two  distinct  points, 
the  supposed  painful  area  and  another  region,  with  the  different 
hands  and  at  the  same  time  distracting  the  patient's  attention  by 
conversation,  one  often  finds  an  absence  of  true  tenderness  at  the 
supposed  seat  of  pain. 

Muscular  rigidity  shows  peritonitic  involvement.  It  may  be 
localized,  as  of  the  right  rectus  in  the  region  of  the  appendix  or 
gall-bladder,  or  over  the  left  rectus,  as  in  diverticulitis  or  phleg- 
monous gastritis,  or  in  abscess  of  the  left  lobe  of  the  liver.  General 
rigidity  shows  general  peritonitis. 

Splashing  Sound  (Clapotage,  Succussion). — If  the  intestines 
contain  liquid  material  and  gas,  tapping  over  them  with  the  fingers 
will  at  times  produce  the  splashing  sound.  The  method  of  differ- 
entiation between  stomach  and  intestinal  splash  has  been  described 
under  Splash  of  the  Stomach  in  Chapter  V. 

In  the  small  intestine  clapotage  can  usually  only  be  obtained  in 
the  dilated  portion  of  the  gut  above  a  stricture.  It  is  not  uncommon 
in  the  large  intestine,  and  can  be  most  often  determined  in  the 
sigmoid  flexure,  caput  coli,  and  the  transverse  colon.  In  case  of 
atony  of  the  bowel  it  is  quite  frequently  present,  also  in  the  relaxed 
abdomen  of  enteroptosis,  and  often  in  patients  with  hysteric  mani- 
festations. 

Boas^  first  suggested  injecting  into  the  bowel  500  cc.  (i  pint)  or 
more  of  water  and  then  examining  for  the  splash  along  the  colon.  It 
should  be  given  with  hips  elevated.  The  splash  will  first  be  secured 
in  the  sigmoid,  and  by  turning  the  patient  on  the  right  side  it  can 
at  times  be  produced  in  the  transverse  colon  and  in  the  cecal  region. 

It  is  possible  to  administer  an  enema  of  moderate  size  and  cause 
it  to  gravitate  to  the  caput  coli  by  the  method  of  rotation  described 
under  Enteroclysis.     By  the  splash  one  can  determine  whether  an 

1  Wiener  klin.  Wochenschr.,  1891,  No.  4. 

2  Diagnostik  und  Therapie  der  Magenkrankheiten,  1897. 


INSPECTION    OF    RECTUM — PROCTOSCOPY    AND    SIGMOIDOSCOPY    40I 

injection  given  for  dysentery  has  passed  through  the  entire  colon 
to  the  cecum. 

In  atony  of  the  bowel,  Boas  produced  the  splash,  even  after  the 
injection  of  only  200  to  300  cc.  (ovj-x)  of  water.  The  position  of 
the  colon  can  be  determined  by  the  splashing  sound  when  it  is 
present;  it  can  be  produced  artificially  by  the  injection  of  water  into 
the  bowel,  and  be  thus  employed  for  locating  the  intestine.  A  little 
Vichy  (siv — 125  cc.)  can  be  added  to  the  injection  to  increase  the 
amount  of  gas. 

Palpation  of  the  Rectum. — The  rectum  is  preferably  palpated 
with  the  index-finger.  Soap  should  be  placed  under  the  edge  of 
the  nail  to  prevent  fecal  material  lodging  therein,  and  the  finger 
lubricated  with  vaselin  or  olive  oil.  It  is  well  to  grease  the  external 
sphincter,  as  it  renders  entrance  of  the  finger  easier.  It  is  more 
cleanly  to  encase  the  finger  with  a  thin  rubber  cot,  or  to  employ  a 
rubber  glove,  well  lubricated. 

■1 


Fig.  171. — A,  soft  rectal  bougie;  B,  cylindric  bougie. 

The  patient  lies  on  the  side,  with  knees  flexed  and  back  to 
examiner,  or  may  be  in  the  knee-elbow  position,  or  stand  with  the 
waist  flexed — leaning  forward  over  a  chair  and  bearing  down  as  if 
to  defecate.  Hemorrhoids,  polypi,  low-seated  stricture,  tender 
points  suggestive  of  ulcer  or  fissure,  malignant  growths,  rectal 
prolapse,  abscess,  fecal  obstruction,  foreign  bodies,  and  intussus- 
ception are  often  within  reach  of  the  examining  finger.  The  pros- 
tate or  uterus  should  be  palpated  during  the  examination.  If  the 
difficulty  is  located  beyond  reach  of  the  palpating  finger,  inspection 
with  the  proctoscope  or  sigmoidoscope  will  give  the  required  infor- 
mation. Simon's  method  of  dilating  the  sphincter  under  anesthesia 
and  passing  the  hand  and  arm  into  the  bowel  for  the  purpose  of 
palpation  is  a  most  dangerous  procedure. 

Palpation  of  the  Rectum  by  Sounds. — This  is  indicated  when  there 
is  suspicion  of  stricture  in  the  bowel  not  accessible  to  the  fingers. 
Soft  rectal  tubes  of  various  caliber  may  be  employed.  When  the 
obstruction  stops  the  passage  of  the  tube,  a  mark  is  made  at  the 

26 


402 


DISEASES   OF   THE   STOMACH   AND   INTESTINES 


external  sphincter,  so  that  the  distance  of  the  stricture  up  the  bowel 
can  be  estimated.  Smaller  tubes  are  then  employed  until  one  can 
pass  the  obstruction.  Its  caliber  is  thus  estimated.  The  ordinary 
soft  flexible  rectal  or  colon-tube  is  the  safest  for  diagnostic  purposes 
in  the  hands  of  the  general  practitioner. 

In  Fig.  I J  I,  A  and  B,  are  shown  an  olive-pointed  flexible  and  a 
cylindric  bougie.  The  latter  is  somewhat  stiff  and  can  be  softened 
in  hot  or  boiling  water  before  use.  This  last  is  also  employed  for 
dilatation  of  the  stricture. 

Kuhn's  metal  spiral  tube  is  of  no  advantage.  Care  should  be 
exercised  if  stiff  tubes  are  employed. 


\ 


Fig.  172. — Auscultatory  percussion  of  the  colon. 


Percussion  should  be  gentle.  Over  empty  intestinal  coils  or 
those  containing  gas  or  air,  a  tympanitic  sound  results,  which  is 
louder  over  the  large  than  over  the  small  bowel.  As  there  may  be 
considerable  distention  of  the  small  intestine,  it  is  sometimes  difficult 
to  delimit  the  large  intestine  by  simple  percussion.  If  the  colon  is 
emptied  by  enema,  and  then  distended  artificially  with  air  or  carbonic 
acid  gas,  the  procedure  is  much  easier. 

Intestinal  coils  which  are  filled  with  liquid  or  solid  material  give 
dulness  on  percussion.  With  meteorism  there  is  tympanites  of  a 
deeper  pitch  than  normal,  and  sometimes  there  is  a  metallic  sound 
with  auscultatory  percussion.     The  meteorism  may  be  localized  or 


INSPECTION   OF    RECTUM — PROCTOSCOPY   AND   SIGMOIDOSCOPY    403 

general.  If  local,  in  connection  with  visible  peristalsis,  intestinal 
stenosis  is  at  once  suggested.  With  local  meteorism  there  will  be 
dull  areas  elsewhere;  with  general  meteorism,  the  entire  abdomen  is 
symmetrically  distended,  the  anterior  portion  being  most  protruded, 
and  there  is  the  diffused  tympanitic  note  of  the  peculiar  type 
noted,  and  dulness  over  the  region  of  the  liver  and  spleen  may  dis- 
appear. With  ascites,  percussion  shows  dulness  in  the  lower  lateral 
regions  of  the  abdomen  and  tympanites  in  the  middle.  The  sounds 
change  on  altering  the  position  of  the  patient  (turning  him  on  his 
side).  The  intestines  ride  up  on  the  fluid,  and  the  upper  flank,  pre- 
viously dull  when  in  the  dorsal  position,  is  now  tympanitic. 

Fecal  accumulation,  tumors, 
and  abscesses  give  dulness  on 
percussion. 

A  %iscultatory  Perciission. — 
This  is  the  best  method  of  deter- 
mining the  position  of  the  colon. 
If  the  small  intestine  is  exces- 
sively distended    it   is  difficult 

to    differentiate  the  percussion  "*', 

sounds.     It   may   be  necessary  A)f 

to  empty  the  colon   by  enema  „.,_  J/ 

or   irrigation    and   then   inflate  B  — — ~~«.«_,>f»^ 

with  air  or  CO2.  Place  the 
stethoscope  at  the  circle  (Fig. 
172)  over  the  cecum;  begin 
percussion  midway  between  the 
umbilicus  and  symphysis,  and 
percuss    to    the    right,    to    the 

left,  and  upward,  in  the  direc-  J 

tion  of  the  arrows,  until  in  each  Fig.  173.— Differential  percussion, 

direction   the  greater  intensely 

altered  quality  and  heightened  pitch  show  that  the  inner  border 
of  the  colon  has  been  reached.  These  points  can  be  marked  on 
the  abdomen  with  a  pencil.  Then  percuss  in  the  epigastric  region 
(midway  between  the  ensiform  and  umbilicus)  downward,  and  from 
the  lateral  lumbar  regions  inward.  The  changes  in  pitch,  quality, 
etc.,  should  be  marked,  and  thus  the  outer  limits  of  the  transverse 
ascending  and  descending  portions  of  the  colon  are  determined. 

The  scratch  method  of  auscultatory  percussion  ma}^  be  carried 
out  in  the  same  lines.  - 

Stengel  claims  that  by  auscultatory  percussion  it  is  possible  to 
determine  that  a  tumor  found  to  lie  in  the  course  of  the  intestine 
originates  in  the  wall  of  the  colon.  In  Fig.  173,  C  represents  the 
tumor;  the  circle  O,  the  stethoscope  placed  over  the  colon  near  the 
tumor;  B,  percussion  note  over  small  intestine;  A,  percussion  over 
normal  large  intestine  near  the  stethoscope. 


X 


^> 


404  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

First  percuss  directly  over  the  tumor,  then  toward  it  from  every 
direction.  The  note  over  tumor,  C,  if  it  is  connected  with  the  colon, 
resembles  the  percussion  note  at  A  (colon)  more  closely  than  does 
percussion  note  at  B  (small  intestine)  resemble  note  at  A  (colon). 

Auscultation. — This  is  not  of  great  significance  in  intestinal 
diseases.  Palpation  may  elicit  a  gurgling  noise  in  the  right  iliac 
fossa,  formerly  thought  to  be  pathognomonic  of  typhoid,  but  it  is 
found  in  many  other  conditions.  Gurgling  sounds  (borborygmi) 
are  at  times  heard.  They  may  be  due  to  fermentative  processes  or 
occur  in  neuroses,  and  are  not  specially  significant. 

The  entire  absence  of  intestinal  sounds  may  be  significant  of 
intestinal  paresis.  If  the  latter  is  due  to  peritonitis,  cardiac  and 
respiratory  sounds  may  be  audible  over  the  entire  abdomen.  Friction 
sounds  from  perisplenitis  or  perihepatitis  may  rarely  be  auscultated. 
With  chronic  stenosis  very  loud  noises  are  at  times  heard,  caused  by 
the  sudden  passage  of  fluid  and  gas  through  the  stricture  under 
pressure. 

Splashing  sounds  are  at  times  distinguishable  in  the  enlarged 
bowel  above  the  stricture. 

TRANSILLUMINATION  OF  THE  INTESTINES 

This  method  was  first  suggested  by  Einhorn^  and  further  practised 
by  Heryng  and  Reichmann.^ 

Einhorn's  technic  is  as  follows:  A  high  enema  or  irrigation  of 
the  bowel  is  first  given.  A  quart  of  water  is  later  injected  per  rectum 
and  the  illuminator,  very  similar  to  the  gastrodiaphane,  is  inserted 
and  gradually  pushed  up  the  intestine.  The  examination  must  be 
made  in  a  dark  room.  Experiments  were  carried  out  by  the  author 
with  specially  devised  illuminators  at  the  Manhattan  State  Hospital. 

As  the  average  adult  rectum  is  8  inches  long,  the  sigmoid  flexure 
17^  inches,  and  allowance  must  be  made  for  the  sphincters,  it  requires 
an  instrument  at  least  J o  inches  in  length  to  pass  through  the  sigmoid 
into  the  descending  colon.  The  30-inch  instruments,  with  which 
I  experimented,  on  almost  every  occasion  caught  and  coiled  back, 
and  rarely  did  I  succeed  in  securing  transillumination  of  the  lowest 
part  of  the  sigmoid,  and  even  then  the  light  was  so  faint  that  it 
was  entirely  unsatisfactory. 

Inflation  of  the  bowel  with  water,  with  fluorescein  solution,  and 
with  air  were  all  tried  before  passage  of  the  light,  as  were  various 
positions  of  the  patient. 

The  experiments  demonstrated  practically  the  impossibility  of 
passing  a  flexible  instrument  or  tube  through  the  sigmoid.  The 
sigmoid  is  quite  movable,  and  Howard  Kelly  has  shown  that  the 
colon-tube  readily  pushes  it  up.  My  experiments  demonstrated 
visually  the  impossibility  of    passing  the  long  colon-tube  through 

1  New  York  Med.  Monatsschrift,  Nov.,  1889. 

2  Therapeutischc  Monatshefte,  1892. 


TRANSILLUMINATION   OF  THE   INTESTINES  405 

the  sigmoid  flexure  and  showed  that  transillumination  of  the  sig- 
moid has  not  been  sufficiently  certain  to  prove  of  practical  value. 

Rontgen  Rays  ;  (^-Rays).— For  examination  of  the  intestines 
the  x-rays  are  of  value  for  the  following  conditions: 

The  determination  of  the  presence  of  a  foreign  body  in  the 
intestinal  tract,  accurately  locating  its  position,  and  hence  the  site 
for  operation. 

Einhorn^  has  recommended  the  internal  administration  of 
bismuth  subnitrate  in  watery  solution  to  locate  the  constriction  in 
acute  intestinal  obstruction  with  the  aid  of  the  x-rays.  The  delay 
necessitated  would  be  dangerous. 

For  locating  the  seat  of  chronic  intestinal  occlusion  the  method 
may  be  of  service. 

An  ounce  (30.0)  of  bismuth  subnitrate  or  bismuth  subcarbonate 
can  be  administered  in  oxij  (375  cc.)  of  milk  or  water,  and  about 
twenty-four  hours  later  examination  should  be  made  with  the  %- 
rays.  With  the  fluoroscope  or  by  a  photograph  one  would  see  a 
distended  area  of  intestine  filled  with  bismuth,  a  region  below  with 
apparently  no  bismuth  or  a  trace  (the  point  of  stenosis),  and  below 
this  a  small  amount  of  bismuth  that  had  passed  through  the 
stricture.  If  the  stricture  is  apparently  in  the  large  intestine,  a 
check  test  can  be  made  as  suggested  by  Einhorn." 

A  few  days  later,  when  the  bowel  is  free  from  bismuth,  an  injec- 
tion per  rectum  is  given  of  500  cc.  (i  pint)  of  water  containing  30  gm. 
(about  oj)  of  bismuth  subnitrate.  If  the  stenosis  is  in  the  large 
intestine  it  will  be  located  by  the  Rontgen  picture,  there  being  the 
area  apparently  free  from  bismuth  (the  stricture)  and  the  collections 
above  and  below  the  stricture. 

Location  oj  the  Colon  by  the  x-Rays. — Two  quarts  (liters)  of  water, 
in  which  60  gm.  (about  2  ounces)  of  subnitrate  of  bismuth  are  sus- 
pended by  means  of  a  little  starch  solution,  are  injected  per  rectum, 
with  the  hips  elevated  or  in  the  knee-elbow  posture.  The  position 
of  the  colon  can  be  immediately  determined  by  the  Rontgen  ray. 

One  could  administer  the  bismuth  by  mouth  and  examine  at  the 
end  of  twenty-four  hours,  but  the  enema  method  is  preferable. 
Misplacements  of  the  colon,  enteroptosis,  and  angulations  of  the 
sigmoid  can  thus  be  determined. 

It  has  been  claimed  that  a  soft  tube,  in  which  lies  a  flexible 
wire,  can  be  introduced  per  rectum,  and  the  course  of  the  colon 
determined  by  the  x-rays,  the  wire  showing  a  shadow.  It  is  prac- 
tically impossible  to  insert  the  tube  beyond  the  sigmoid,  so  the 
method  is  not  accurate.  The  x-ray  pictures  shown  of  the  long 
colon-tube — supposedly  in  the  descending  colon — are  usually  in  the 
ampulla  of  the  rectum.     H.  W.  Soper^  has  demonstrated,  by  means 

1  New  York  Med.  Journal,  May  18,  1907. 

2  Ibid. 

^Jour.  Am.  Med.  Assoc,  Aug.  7,  1909. 


406  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

of  the  jc-rays  that  it  is  impossible  to  pass  the  colon-tube  into  the 
sigmoid,  except  in  the  case  of  Hirschsprung's  disease  (congenital 
idiopathic  dilatation  and  hypertrophy  of  the  colon). 

For  locating  the  position  of  the  colon  the  Rontgen  method  is  expen- 
sive and  usually  impractical,  as  it  gives  no  more  information  than 
by  inflation. 

Physiologic  Investigations  with  Rontgen  Rays. — Cannon^  has  in- 
vestigated intestinal  movements  after  administration  of  bismuth  by 
means  of  the  :r-rays.  He  experimented  on  cats,  and  claims  there 
are  periodic  antiperistaltic  movements  in  the  cecum  and  ascending 
and  transverse  colon  which  aid  in  churning  and  mixing  the  contents, 
and  so  help  absorption.  He  holds  that  some  of  the  material  may  be 
forced  back  into  the  small  intestine,  and  that  this  may  occur  with  a 
high  nutrient  enema. 

Some  investigators  disagree  with  Cannon.  Griitzner  has  shown 
that  starch  granules,  lycopodium,  powdered  carbon,  etc.,  in  physio- 
logic salt  solution,  injected  into  the  bowel  under  favorable  circum- 
stances, will  find  their  way  upward  into  the  stomach. 

By  means  of  the  rjc-rays  Hemmeter  observed  that  the  upward 
movement  of  these  particles  goes  on  simultaneously  with  the  down- 
ward movement  of  the  feces,  i.  e.,  there  is  upward  marginal  current. 
He  considers  the  epithelia  and  muscularis  mucosa  instrumental,  and 
that  it  is  not  true  antiperistalsis. 

INFLATION  OF  THE  INTESTINES  WITH  CARBONIC  ACID  GAS  OR  AIR 

Von  Ziemssen^  first  employed  inflation  of  the  colon  for  diagnostic 
purposes  by  injecting  in  succession  into  the  bowel  solutions  of  tartaric 
acid  and  sodium  bicarbonate,  with  the  resulting  development  of 
carbonic  acid  gas.  The  bowel  could  then  be  recognized  by  the 
marked  tympanitic  sounds  on  percussion  or,  more  rarely,  by  inspec- 
tion.    Preferably,  the  gut  should  be  previously  emptied  by  enema. 

Inject  into  the  bowel  5j  (4.0)  of  tartaric  acid,  which  has  been 
dissolved  in  ovj  to  viij  (200-250  cc.)  of  water,  and  follow  it  by  the 
injection  of  the  same  quantity  of  soda  bicarbonate  in  same  amount 
of  water.     Preferably  the  hips  should  be  elevated. 

Schnetter  suggested  attaching  a  flexible  tube  with  rectal  tip  to 
the  nozzle  of  an  inverted  soda-water  siphon  and  driving  out  the 
CO2  by  pressing  the  valve. 

The  gas  has  also  been  injected  by  obtaining  it  from  the  liquefied 
gas  in  a  sparklet  and  conducting  the  CO2  from  a  bottle  into  the  rectum. 

One  of  the  simplest  methods  to  inflate  the  bowel  by  means  of  carbonic 
acid  gas  is  by  Rose's  gas  bottle.  This  consists  of  a  moderate-sized 
bottle  with  perforated  cork,  through  which  passes  a  glass  tube.  To 
this  is  attached  a  soft-rubber  tube  and  rectal  tip  (Fig.  174). 

The  bottle  is  half -filled  with  water  and  5j  (4-00)  each  of  tartaric 

1  American  Journal  of  Physiol.,  vol.  vi,  p.  253. 

2  DeutschesArchiv.  f.  klin.  Medizin,  1883,  Bd.  38,  S.  325. 


INFLATION    OF    INTESTINES    WITH    CARBONIC    ACID    GAS    OR    AIR    407 

acid  and  soda  bicarbonate  added,  and  the  cork  tightly  inserted. 
The  accumulating  gas  is  conducted  off  by  the  tube  into  the  rectum. 
Inspection  and  percussion  will  determine  the  extent  of  distention. 

Runeberg^  recommended  inflation  of  the  intestines  by  air  by  means 
of  a  colon-tube,  to  which  a  compressible  air  bulb  is  attached.  It  is 
possible  by  this  means  to  measure  and  regulate  the  quantity  of  air 
employed  for  inflation- 

An  ordinary  Davidson's  syringe  can  be  used  to  pump  in  the  air, 
and  its  capacity  can  be  determined  as  follows: 

Take  a  measuring  glass  of  i  pint  (500  cc.)  to  i  quart  (liter)  or 
a  glass  vessel  of  unknown  capacity  and  measure  its  capacity  when 
filled  to  the  brim.  Invert  the  filled  vessel  in  a  pail  of  water,  so  that 
the  entire  column  of  water  is  sustained  in  the  inverted  vessel.  Then 
slip  the  colon-tube  under  water,  so  that  its  tip  enters  the  inverted 
jar.     Observe  how  many  compressions  of  the  bulb  are  required  to 


Fig.  174. — Rose's  carbonic  acid  gas  generator. 

replace  the  water  column  with  air,  that  is,  to  drive  out  all  the  water 
from  the  inverted  vessel. 

If,  for  example,  the  jar  contained  500  cc.  (i  pint)  and  it  required 
sixteen  squeezes  of  the  bulb  to  replace  this  by  air,  then  each  squeeze 
of  the  bulb  replaces  i  ounce  of  water  by  the  air  equivalent. 

Uses  of  Inflation. — It  is  of  service  to  detect  stenosis  of  the 
large  intestine.  Under  normal  conditions  the  injected  air  distends 
the  colon  evenly.  If  there  is  stenosis,  the  air  will  distend  chiefly 
that  part  of  the  bowel  below  the  stricture,  while  above  it  remains 
unchanged.  This  is  true  in  marked  strictures,  but  in  those  of  mild 
type  the  air  will  pass  through.  Even  in  some  such  cases  there  will 
be  less  distention  above  than  below  the  strictured  point. 

The  position  of  the  colon  can  be  determined  by  air  inflation. 
Normally  it  passes  with  a  slight  downward  curve  across  the  abdomen 
with  lower  edge  about  touching  the  upper  margin  of  the  umbilicus. 

Enteroptosis  is  demonstrated  by  this  method  and  the  transverse 

1  Deutsches  Archiv.  f.  klin.  Med.,  Bd.  34,  S.  460. 


4o8  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

colon  may  descend  to  a  hand's  breadth  above  the  symphysis.  It  may 
assume  a  V  shape.  Angulations  of  the  sigmoid  may  at  times  be 
determined  by  this  means. 

For  the  diagnosis  of  the  location  of  abdominal  tumors  inflation 
of  the  intestine  is  often  of  service.  After  inflation  of  the  colon  with 
air,  tumors  of  the  viscera  become  more  distinct;  while  tumors  of  the 
kidney,  retroperitoneal  glands,  spine,  etc.,  tend  to  disappear. 

Minkowski^  holds  that  after  filling  the  colon  with  air  or  water, 
abdominal  tumors  are  shifted  in  the  direction  of  the  organ  to  which 
they  belong. 

Sutton^  suggests  inflating  the  bowel  with  air  impregnated  with 
ether  for  the  diagnosis  of  intestinal  perforation.  He  employs  a  bottle 
provided  with  a  perforated  rubber  cork  to  which  are  attached  two 
rubber  tubes  with  stop-cocks.  To  one  of  these  tubes  is  attached  a 
bicycle  pump  or  a  Davidson's  syringe;  to  the  other  an  ordinary 
colon-tube  by  means  of  a  short  glass  connecting  tube. 

Two  drams  of  ether  are  placed  in  the  bottle.  The  air  pumped 
into  the  bowel  passes  through  the  bottle  and  thus  takes  up  the  vapor 
of  ether.  With  the  stop-cocks  the  pressure  of  ether  and  air  can  be 
regulated. 

If  perforation  of  the  bowel  is  present,  the  ether  escapes  through 
the  opening  into  the  abdominal  cavity  and  distends  it  equally  in  all 
directions.  If  there  is  no  perforation,  first  the  large  intestine  and 
later  the  small  intestine  become  filled  with  air  and  ether,  and  finally 
ether  vapor  may  be  eructated  and  readily  recognized.  This  method 
is  useful  in  gunshot  wounds  of  the  abdomen. 

Inflation  of  the  Colon  with  Water. — This  can  be  performed 
with  a  graduated  irrigating  jar  and  a  rectal  tube.  With  a  fountain 
syringe  of  known  capacity  it  is  easy  to  estimate  the  quantity  injected. 

In  stricture  of  the  colon,  especially  in  the  lower  portion,  the  quan- 
tity of  water  which  can  be  injected  is  not  great.  Normally  the  colon 
will  contain  from  3  to  4  quarts,  or  occasionally  5,  without  dangerous 
distention.  The  injection  should  be  given  with  hips  elevated. 
Many  people  are  unable  to  hold  any  quantity  of  water  in  the  bowels 
without  pain,  discomfort,  and  rapid  evacuation  of  the  fluid. 

Determination  of  the  position  of  the  colon  by  inflating  it  with 
water  is,  therefore,  often  difficult.  The  air  inflation  is  preferable 
for  the  above  reasons. 

LAVAGE  OF  THE  BOWEL  FOR  DIAGNOSIS 

Boas^  first  recommended  this  procedure  to  be  carried  out  in  a 
manner  similar  to  lavage  of  the  stomach.  The  bowels  should  be 
previously  evacuated.  The  patient  should  lie  on  the  side  with  the 
knees  and   thighs   flexed.     The  colon-tube  is  attached  by  a  short 

1  Berlin,  klin.  Wochenschr.,  18S8,  No.  31. 

2  Journal  Am.  Med.  Association,  Dec.  30,  1899. 
^Deutsch.  Aertze-Zeitung,  1895,  Nos.  2  and  3. 


EXAMINATION    OF    THE    FECES  409 

piece  of  metal  or  glass  tubing  to  a  long  tube,  provided  with  a  funnel. 
The  rectal  tube  is  lubricated  and  inserted  high  up  to  its  full  length 
and  about  500  cc.  (i  pint)  to  i  liter  (quart)  gradually  poured  in 
through  the  funnel  held  i  or  2  feet  above  the  patient,  until  some 
discomfort  is  expressed.  The  funnel  is  then  lowered  below  the  anus 
and  the  contents  siphoned  off. 

They  are  then  submitted  to  a  thorough  examination.  Normally 
the  contents  are  fairly  clear  or  slightly  stained  with  fecal  matter  and 
contain  a  little  mucus  and  a  few  epithelial  cells. 

With  intestinal  catarrh  a  large  amount  of  mucus  is  present. 
Blood  or  pus  may  be  found,  showing  hemorrhages  or  a  suppurative 
process,  such  as  an  ulcer  or  abscess.  ExfoHated  portions  of  the 
mucous  membrane  may  occasionally  be  found  or,  rarely,  tumor 
fragments. 

Microscopic  examination  of  such  material  is  of  diagnostic  impor- 
tance. Intestinal  worms  are  occasionally  discovered.  Lavage  of 
the  bowel  is  also  employed  for  the  removal  of  dysenteric  discharge 
and  mucus,  for  the  purpose  of  examination  for  amebae. 

EXAMINATION  OF  THE  FECES 
The  Stool. — General  Considerations. — ^The  normal  stool  consists 
of  changed  and  unchanged  remnants  of  food,  bacteria   (estimated 
at  about    126  billions  daily),   epithelial  cells,   salts,   and  traces  of 
the  digestive  juices. 

The  normal  daily  quantity  under  a  mixed  diet  averages  100  to  . 
even  200  gm.  (3^  to  7  ounces).  It  may  be  increased  by  a  vegetable 
diet.  There  is  usually  one  movement  daily  of  dark  brown  color, 
though  diet  and  medicine  have  an  influence.  Milk  gives  a  hght 
yellow;  claret  and  huckleberries,  a  brownish  black;  salts  of  iron  and 
magnesia,  a  blackish  brown ;  bismuth,  black.  Blue  is  given  by  iodids 
(long  continued);  green,  by  calomel;  yellow,  by  santonin,  senna, 
and  rhubarb;  violet,  by  salol  and  betanaphtol.  The  feces  are 
slightly  soft  and  of  sausage  shape.  Abnormally  they  may  appear 
in  small  balls,  cylinders  or  tape-like,  or  as  hard  scybalae  (dry  in 
character),  or  they  may  be  mushy  or  liquid.  They  may  be  very 
watery,  as  in  choleraic  conditions,  or  fluid  and  mixed  with  mucus. 

Odor.— This  is  normally  caused  by  skatol  and  sHghtly  by  indol. 
It  is  increased  when  the  feces  have  been  retained  an  abnormal  time. 
After  a  short  sojourn  in  the  intestines,  as  Avith  rice-water  move- 
ments, there  is  often  no  odor.  The  character  of  the  food  may  affect 
the  odor.  Very  fetid  movements  occur  with  ulcerative  processes  or 
with  malignant  growths. 

Macroscopic  Findings. — Remnants  of  Food  in  the  Feces. — 
Undigested  remnants  of  food  can  often  be  seen  in  the  stool.  Nor- 
mally they  consist  of  only  small  particles  of  vegetable  material,  such 
as  potato,  asparagus,  spinach,  and  peas;  while  remnants  of  meat 
cannot  be  seen.     Providing  abnormal  quantities  of  food  have  not 


4IO  DISEASES   OF   THE   STOMACH  AND   INTESTINES 

been  ingested,  it  is  often  possible  to  draw  definite  conclusions  as  to 
the  state  of  intestinal  digestion,  from  the  excess  of  one  form  of 
non-digested  material  over  another.  The  presence  of  large  quantities 
of  undigested  starch  indicates  a  catarrhal  condition  of  the  small  intestine, 
and,  indeed,  more  than  traces  of  this  material  should  be  regarded  with 
suspicion.  If  particles  of  meat  are  visible,  this  indicates  a  lesion  of 
the  intestinal  tract.  Connective-tissue  fibers  appearing  unaltered 
in  the  feces  indicate  deficient  gastric  digestion,  according  to  Schmidt, 
and  the  presence  of  nuclei,  under  the  microscope,  disturbance  of  the 
trypsin  function  of  the  pancreas. 

Blood. — Blood  may  be  visible  in  the  feces,  either  fresh  (red)  or 
dark  in  color  and  un coagulated,  which  shows  its  origin  from  the 
lower  part  of  the  large  bowel.  It  may  appear  changed,  giving  the 
feces  the  appearance  of  tar,  then  originating  from  the  small  intes- 
tine or  even  from  the  stomach.  Blood  shows  the  presence  of  an 
ulceration  or  of  an  ulcerating  cavity  communicating  with  the  gut. 

Pus. — Visible  pus  in  the  dejecta  only  occurs  when  pus  exists  in 
large  quantities  in  the  lower  part  of  the  large  intestine.  It  shows 
ulceration  or  an  abscess  communicating  with  the  gut.  Pus  in  small 
quantity  or  from  higher  up  the  intestine  can  only  be  determined  by 
the  microscope. 

Fragments  of  tumor  (polypi  or  cancer)  may  rarely  be  found  in 
the  dejecta.  Microscopic  examination  will  give  important  infor- 
mation. 

Mucus. — Mucin  can  always  be  detected  in  normal  feces  by  chemic 
examination.  The  amount  of  mucus  in  the  feces  in  health  is  so 
small  and  so  intimately  mixed  as  to  be  only  recognized  by  chemic 
tests.  Mucus  in  the  stool,  either  macroscopic  or  microscopic,  indi- 
cates some  deviation  from  the  normal  physiologic  condition.  It 
does  not  invariably  show  an  anatomic  lesion.  We  may,  for  ex- 
ample, have  a  few  flakes  of  mucus  or  an  extremely  thin  layer 
adherent  to  scybalae,  due  to  irritation  of  the  mucosa  from  a  fecal 
accumulation  or  impaction,  or  mucus,  which  is  contained  normally 
in  the  higher  portions  of  the  small  intestine,  may  occasionally  ap- 
pear in  the  stool  as  a  result  of  increased  peristalsis. 

Under  other  circumstances  the  presence  of  mucus  is  pathologic. 
Macroscopically,   mucus  may  exist  as  follows: 

(i)  An  abundant  coating  in  the  form  of  a  glassy  layer  may  cover 
fecal  masses.  It  may  be  gray  or  cloudy  from  epithelial  or  round 
cells.  This  usually  indicates  catarrh  of  the  lower  portion  of  the 
bowel.  / 

(2)  It  may  be  intimately  mixed  with  the  feces  in  mushy  move- 
ments, and  may  adhere  to  a  glass  rod  if  this  is  dipped  in  the  stool. 

(3)  It  may  float  on  top  of  watery  movements. 

(4)  It  may  be  passed  almost  pure  in  large  amount. 

Material  resembling  frogs'  spawn  or  sago  grains  may  occur  in  the 
feces.     They  were  formerly  considered  due  to  follicular  ulceration, 
17 


EXAMINATION    OF    THE    FECES  4II 

but  are  now  believed  to  be  of  vegetable  origin.     Kitagawa  holds  that 
some  of  them  are  pure  mucus,  but  that  they  are  not  pathologic. 

Yellow  or  yellowish  brown  granules  occur  in  the  stool,  from  the  size 
of  a  pinhead  to  a  poppy  seed,  resembling  butter  in  consistency.  Some 
of  these  have  been  considered  bile-stained  mucus,  while  other  frag- 
ments are  believed  to  be  albuminous  or  vegetable  material  or  yellow 
calcium  salts. 

Boas  and  Schmidt  beUeve  these  yellow  granules  to  be  albuminous 
matter  stained  with  bile-pigment. 

The  presence  of  any  one  of  the  previously  described  types  of 
mucus  indicates  intestinal  catarrh.  Mucus  without  feces  or  sur- 
rounding the  feces  shows  the  colon  is  inflamed.  When  mucus  is 
mixed  with  the  feces  the  upper  colon  or  small  intestine  is  inflamed. 
Mucus  in  the  food  residue  shows  catarrh  of  the  small  intestine. 

There  are  two  exceptions  to  the  rule  that  visible  mucus  indicates 
catarrh: 

(i)  In  mucous  colic  (membranous  enteritis)  pure  mucus  due  to 
hypersecretion  is  evacuated  in  the  form  of  a  cast  membrane  or  in 
long  tape-like  formation. 

(2)  In  intestinal  dyspepsia  with  acid  fermentation  the  patient 
has  a  jejunal  diarrhea,  with  gelatinous,  tenacious,  semifluid  stools. 
Mucus  is  present. 

Epithelial  or  round  cells,  which  are  abundant  in  catarrhal  mucus, 
are  absent  from  the  mucus  in  dyspepsia  of  the  small  intestine.  The 
stools  are  also  green,  acid,  and  give  a  bile-pigment  reaction. 

Intestinal  parasites  may  be  visible  in  the  feces. 

Chemic  Examination  of  the  Feces. — Reaction  is  normally 
neutral  or  slightly  alkaline.  Marked  acidity  results  from  occlusion 
of  the  bile-duct.  Rich  vegetable  diet  causes  slight  acidity.  The 
simplest  method  to  test  the  reaction  is  by  litmus-paper  (red  and 
blue). 

Normal  stools  react  slightly  differently  with  different  indicators. 
With  pheriolphthalein  they  react  slightly  acid,  while  to  litmus  they 
would  be  neutral.  If  the  phenolphthalein  test  is  employed,  take 
feces  5.0,  rub  up  in  a  mortar,  and  add  30.0  cc.  distilled  water,  after 
the  modified  Schmidt  diet.  Place  2  cc.  of  this  in  a  test-tube,  add 
2  drops  of  I  per  cent,  alcoholic  solution  of  phenolphthalein.  With 
this  quantity  titration  with  decinormal  sodium  hydrate  never 
exceeds  1.5  cc.  to  secure  end-reaction.  Above  this  the  stool  should 
be  considered  acid,  and  if  less  than  i  cc.  it  may  be  considered  alka- 
line (Kaplan^). 

For  general  use  the  litmus  test  is  sufficient. 

Test  for  Mucin. — Mucin  is  normally  present  in  the  feces.  Mix 
feces  with  water  and  an  equal  quantity  of  milk  of  lime  and  let  the 
mixture  stand  for  several  hours.  Then  filter,  add  acetic  acid  to 
filtrate,  and  mucin  precipitates  if  present. 

1  New  York  Medical  Journal,  Dec.  7,  1907. 


412  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

To  Examine  Separate  Particles  of  Suspected  Mucus. — Dissolve 
a  flake  of  material  in  a  weak  solution  of  potassium  or  sodium  hydrate 
and  add  acetic  acid.  If  the  precipitate  is  undissolved  after  adding 
the  acid  in  excess,  mucin  is  present.  Heat  the  precipitate  to  the 
boiling-point  in  a  dilute  mineral  acid ;  if  mucin  is  present  the  heated 
solution  will  reduce  copper  oxid.  This  last  test  excludes  nucleo- 
albumin,  which  otherwise  gives  a  similar  reaction  (Einhorn).  Stain 
a  flake  of  apparent  mucus  with  a  weak  triacid  solution  (Ehrlich), 
mucus  produces  a  green  color;  albumin,  red.  This  test  is  of  value 
in  determining  the  presence  of  mucus  in  membranous  specimens 
from  mucous  colic.     The  tests  otherwise  are  rarely  required. 

Albumin. — Treat  the  feces  with  water  slightly  acidified  with 
acetic  acid.  Filter  the  watery  extract  and  employ  boiling  test  as 
for  albumin  in  the  urine.  Normally  no  albtimin  is  present,  but  it 
has  been  found  in  typhoid,  occasionally  in  acute  enteritis,  and  in 
chlorosis. 

Propeptone  and  Peptone. — After  the  test  for  albumin  has  proved 
negative,  the  watery  extract  of  the  feces  is  treated  with  phospho- 
tungstic  acid,  the  precipitate  is  diluted  with  water  and  sodium 
hydrate,  and  a  small  amount  of  a  weak  solution  of  sulphate  of 
copper  added.  A  purple  red  (biuret  reaction)  shows  the  presence 
of  both  propeptones  and  peptones.  To  determine  the  presence  of 
peptones  separately,  first  precipitate  the  propeptones  by  ammonium 
sulphate  in  large  amount. 

Pathologically,  peptone  is  found  in  typhoid,  d^'sentery,  tubercu- 
lous ulcer  of  the  intestine,  and  in  perforative  peritonitis.  Normally 
it  is  not  present. 

Carbohydrates. — The  feces  are  first  subjected  to  distillation. 
The  residue  is  extracted  with  alcohol  and  ether;  the  extract  boiled 
with  water,  filtered,  and  again  boiled,  with  the  addition  of  dilute 
sulphuric  acid.     Trommer's  or  Nylander's  test  is  then  employed. 

Examination  for  Starch. — The  watery  extract  of  feces  is  examined 
with  Lugol's  solution,  the  presence  of  starch  producing  a  blue  color. 

For  Sugar. — A  watery  extract  of  feces  can  be  directly  tested  by 
Fehling's  method. 

Normally,  neither  starch  nor  sugar  are  found. 

Gas  Fermentation. — Schmidt's  method  will  be  described  later. 

Fat. — The  feces  are  treated  with  considerable  ether,  and  the 
latter  is  separated  and  evaporated  in  a  water-bath.  The  neutral 
fat,  if  present,  remains  visible. 

To  show  the  presence  of  soaps  which  do  not  dissolve  in  ether, 
another  portion  of  fecal  matter  is  first  treated  with  acids  which  split 
up  the  soaps,  and  then  extracted  with  ether ;  quantitative  determina- 
tion is  complicated. 

Normally,  fat  is  never  present  macroscopically  in  the  stools 
unless  after  ingestion  of  very  large  quantities.  It  may  then  be 
visible   in  very  small  portions,  the  size  of  a  pea.      Pathologically, 


EXAMINATION    OF   THE    FECES  413 

fat  may  exist  in  large  quantities  in  the  fecal  matter  and  give  the 
grayish-silver  fatty  stools,  especially  in  disease  of  the  pancreas  and 
whenever  lymphatic  absorption  is  disturbed. 

Blood. — Fresh  blood  can  often  be  recognized  macroscopically. 
The  tests  for  occult  (concealed)  blood  are  of  importance.  The  best 
methods  are  the  benzidin  test  (the  latest) ;  Weber's  modification  of 
the  guaiac  test ;  and  the  aloin  test.  These  are  fully  described  under 
Tests  for  Occult  Blood  in  the  Stomach  Contents  and  Stools  in  Part  II 
of  this  volume.  Neither  meat  nor  iron 
preparations  should  be  ingested  for  two  to 
three  days  previous  to  the  tests.  The 
hemin  test  has  been  employed.  A  small 
particle  of  fecal  material  is  dried,  pow- 
dered, and  placed  on  a  slide.  A  trace  of 
sodium  chlorid  is  added  and  a  drop  of 
glacial  acetic  acid  poured  on  and  thor- 
oughly mixed.  A  cover-glass  is  placed 
over  the  specimen  and  the  slide  slowly  pig.  lys.-Hematin  crystals. 
heated.  After  cooling,  a  microscopic  ex- 
amination is  made.  In  the  presence  of  blood,  hematin  crystals  are 
found  (Fig.  175).     These  are  reddish  pink  and  rhomboid  in  shape. 

Bile-pigment. — Normally,  no  unchanged  bile-pigment  is  found 
in  the  feces.  In  catarrh  of  the  small  intestine  it  has  been  detected. 
The  presence  of  bile-pigment  is  determined  as  follows:  A  particle 
of  the  colored  fecal  matter  is  brought  into  contact  with  a  drop  of 
fuming  nitric  acid.  The  yellow  color  passes  through  the  various 
colors  of  the  spectrum,  red,  violet,  to  green;  in  some  cases  green 
appears  at  once;  or  liquid  feces  can  be  filtered  through  filter-paper, 
or  a  watery  mixture  can  be  made  and  then  filtered.  The  paper  is 
then  dried  and  a  drop  or  two  of  the  fuming  nitric  acid  poured,  on  it. 
The  colors  will  appear  in  rings  if  bile  is  present ;  or : 

A  small  quantity  of  the  feces  is  treated  with  a  concentrated 
watery  solution  of  corrosive  sublimate.  Biliary  pigments  will  turn 
the  mixture  green,  or  green  appears  in  that  portion  where  pigments 
are  -present. 

Biliary  Acids. — ^These  usually  accompany  biliary  pigments. 
They  are  revealed  by  Pettenkofer's  test:  A  small  quantity  of  feces 
is  treated  with  alcohol  and  then  the  latter  is  evaporated.  To  the 
residue  a  weak  watery  solution  of  bicarbonate  of  soda  is  added,  and 
to  this  mixture  a  small  amount  of  cane-sugar  and  a  few  drops  of 
sulphuric  acid.     Red  or  pink  occurs  when  biliary  acids  are  present. 

Urobilin. — Normally,  the  biliary  pigment  in  the  intestinal  tract 
becomes  changed  to  urobilin,  which  gives  the  brown  color  to  the 
feces. 

A  small  piece  of  fecal  matter  is  treated  with  a  concentrated  watery 
solution  of  corrosive  sublimate  and  thoroughly  mixed  with  a  glass 
rod.     Urobilin  gives  rise  to  a  pinkish-red  color;  bilirubin,  to  a  green 


414  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

color.  Urobilin  is  normally  present  and  is  absent  in  pathologic  con- 
ditions, while  bilirubin  is  present  in  the  latter. 

Fleischer's  Test. — Place  a  small  quantity  of  feces  in  a  test-tube 
with  a  small  amount  of  alcohol  to  which  has  been  added  a  few  drops  of 
h^'^drochloric  or  acetic  acid.  After  a  short  time  urobilin  produces  a  yel- 
low^ or  brown  color.  If  the  alcohol  is  then  poured  off  and  a  few^  drops 
of  sodium  hvdrate  wdth  a  small  quantity  of  zinc  chlorid  are  added, 
there  appears  a  green  fluorescence  in  direct  rays  of  Hght,  and  in  trans- 
mitted light,  pink  or  yellowish  red,  greater  or  less  in  proportion. 

Acholic  and  Colorless  Stools. — The  acholic  stool  presents  a 
grayish-white,  ash-gray,  or  clay  color  due  to  absence  of  bile-pigment. 
The  dejecta  are  of  penetrating  odor,  buttery  consistency,  and  on 
chemic  and  microscopic  examination  are  found  to  contain  much  fat. 
The  latter  is  present  as  needle-shaped  crystals  or  in  sheaves  of 
crystals  or,  less  generahy,  in  fat-droplets.  This  type  of  stool  occurs 
in  conditions  such  as  occlusion  of  the  bile-duct,  when  there  is  an 
exclusion  of  bile  from  the  intestine. 

Stools  may  be  entirely  devoid  of  color  or  of  a  gra^dsh-white  color 
resembling  true  achoHc  stools,  though  there  is  no  jaundice  or  occlusion 
of  the  bile-ducts.  These  stools  are  less  putrid  in  odor  and  more  acid. 
They  contain  enormous  amounts  of  fat,  Hke  the  true  acholic  stool, 
and  urobilin  has  been  demonstrated  in  them.  Such  movements  occur 
in  conditions  when  the  absorption  of  fat  is  impaired,  as  in  tuberculosis 
of  the  intestines  and  peritoneum.  At  other  times  abnormal  quantities 
of  fat  are  not  present,  and  the  lack  of  color  is  imputed  to  the  presence 
of  a  colorless  decomposition  product  of  bilirubin,  the  leuko-urobilin 
of  Mencki. 

The  conclusion  that  a  stool  contains  an  excessive  amount  of  fat 
because  it  is  apparently  acholic  is  not  justifiable  unless  a  microscopic 
examination  is  made.  An  apparently  acholic  stool  may  also  be  due 
to  excessive  fat  and  urobilin  be  present. 

Fatty  Stools  (Steatorrhea) . — This  term  is  applied  to  all  cases 
in  which  isolated  masses  of  fat  are  present  in  the  feces  and  can  be 
recognized  with  the  naked  eye.  It  appears  in  whitish  or  grayish 
lumps,  or  it  may  cling  around  the  feces  or  be  adherent  to  the  vessel. 

Ingestion  of  excessive  fat  even  under  normal  conditions  may 
produce  an  evacuation  of  superfluous  fat.  If  the  mucosa  of  the 
small  intestine  and  the  lymphatic  system  (mesenteric  glands)  lose 
their  powers  of  absorption,  fat  must  appear  in  the  stools,  as  in 
tuberculosis  of  the  small  intestine,  chronic  tubercular  peritonitis, 
intestinal  catarrh,  etc. 

In  occlusion  of  bile  from  the  intestines  with  acholic  stools,  the 
fat  is  revealed  microscopically  and  by  chemic  analysis,  but  fatty 
stools  are  not  then  spoken  of  in  the  clinical  sense. 

Steatorrhea  is  not  per  se  diagnostic  of  pancreatic  disease.  In 
the  absence  of  icterus  and  of  demonstrable  intestinal  disease,  fatty 
stool  is  probably  due  to  pancreatic  disease.     Disturbed  digestion  of 


EXAMINATION   OF   THE    FECES 


415 


fat  is  diagnostic  of  pancreatic  disease.  Miiller  shows  that  qualitative 
changes  in  the  fat  (Hpolysis)  is  much  sHghter,  only  39.8  per  cent,  in 
pancreatic  disease,  where  it  is  84  per  cent,  in  healthy  subjects,  or 
even  in  those  with  icterus,  if  the  pancreatic  juice  has  free  access. 

Ferments. — A  glycerin  extract  can  be  made  of  the  feces  or  the 
fecal  matter  may  be  mixed  with  water  containing  a  small  proportion 
of  thymol  and  filtered. 

To  test  for  trypsin,  the  filtration  extract  is  made  alkaline  by  the 
addition  of  soda  bicarbonate  and  a  few  flakes  of  fibrin  added.  The 
solutions  are  kept  at  a  blood  temperature  for  a  few  hours  and  then 
tested  with  potassium  hydrate  and  a  weak  solution  of  copper  sul- 
phate. If  trypsin  is  present,  there  will  be  a  pinkish-red  reaction 
(biuret)  in  consequence  of  peptone. 

For  Diastase. — A  few  cubic  centimeters  of  the  filtrate  are  mixed 
with  about  one-half  the  amount  of  a  starch  solution  and  kept  at  a 


Fig.  176. — Einhorn's  stool  sieve. 

blood  temperature  for  about  thirty  minutes.  The  mixture  is  then 
subjected  to  Fehling's  or  Trommer's  test.  Normally,  these  ferments 
are  absent,^  but  in  pathologic  conditions,  especially  in  diarrhea,  they 
are  frequently  found.  Wynhausen"  describes  a  new  test  for  the 
pancreatic  activity.     Further  investigations  are  advisable. 

Concretions,  Foreign  Bodies,  Worms. — To  examine  for  such 
material  the  feces  should  be  thoroughly  mixed  with  water  and 
poured  through  a  sieve.  This  can  be  improvised — a  circular  wire 
rim  can  be  fitted  to  a  water-closet  seat,  and  attached  to  the  wire 
a  network  bag  made  of  two  thicknesses  of  cheese  cloth,  practically 
a  dip  net.  The  patient  defecates  in  the  net,  and  water  can  then  be 
poured  through  several  times  until  only  the  more  solid  parts  remain. 

1  Goldschmidt  (Deut.  med.  Wochenschr.,  1909,  No.  12,  xxv,  522)  and  Gross 
(Ibid.,  1909,  No.  16,  xxv,  706),  u.sing  the  latter's  method  for  detecting  trypsin, 
have  discovered  it  in  the  feces  of  all  normal  persons  examined.  This,  if  con- 
firmed, will  prove  a  great  advance. 

2  Berliner  klin.  Wochenschr.,  July  26,  1909;   also  Med.  Record,  Sept.  11,  1909. 


41 6  DISEASES   OF   THE    STOMACH   AND    INTESTINES 

Boas  has  constructed  a  stool  sieve  and  Einhorn's,  as  in  Fig.  176, 
is  readily  understood.  Water  is  poured  through  and  there  is  a  stirring 
apparatus. 

Concretions. — Among  such  are  gall-stones,  pancreatic  calculi, 
enteroliths,  and  coproliths.  Biliary  calculi  are  readily  recognized 
when  of  any  size.  The  principal  constituents  are  cholesterin,  bile- 
pigment,  and  lime. 

Tests  for  small  biliary  concretions  (sand)  are  as  follows:  first, 
powder  gr.  30  (2.0)  of  the  mass  and  treat  with  ether,  3v  (20  cc),  mix 
and  filter,  evaporate,  and  test  for  cholesterin.  Dissolve  part  of 
residue  in  hot  alcohol  and  allow  it  to  evaporate.  Microscopic 
examination  of  the  precipitate  shows  rhomboid  crystals  with  ragged 
edge  (cholesterin) ;  second,  another  part  of  the  residue  is  placed  on 
a  slide,  a  drop  of  concentrated  sulphuric  acid  added  and  covered 
with  a  cover-glass,  the  cholesterin  crystals  become  carmine  at  their 
edges,  add  i  drop  of  Lugol's  solution  and  a  violet  color  arises;  finally, 
a  portion  of  the  residue  is  treated  with  hydrochloric  acid,  a  trace  of 
iron  chlorid,  and  then  evaporated.  If  cholesterin  is  present,  a  blue 
color  occurs. 

The  residue  of  the  original  ether  mixture  is  treated  with  dilute 
hydrochloric  acid  mixture,  heated,  and  extracted  with  chloroform 
after  cooling.  The  chloroform  extract  is  tested  with  Gmelin's 
reaction  (fuming  nitric  acid).  Bile-pigment  produces  the  rainbow 
play  of  colors. 

Pancreatic  Calculi. — These  usually  have  a  rough  surface,  are 
brittle,  and  may  be  faceted.  They  are  soluble  in  chloroform,  and  on 
evaporation  produce  an  aromatic  odor.^  Bile-pigment  and  choles- 
terin are  absent. 

Enteroliths. — Calculi  formed  in  the  small  intestine  consist  of 
inorganic  salts  (lime  and  magnesia).  They  are  light  in  color  and 
usually  of  small  size.  They  form  occasionally  after  the  extensive 
use  of  lime  and  magnesia.     Rarely  they  cause  obstruction. 

Coproliths  {fecal  calculi)  are  found  in  the  large  bowel,  chiefly 
where  there  is  retardation  to  the  passage  of  feces,  as  in  the  cecum, 
appendix,  sacculi  of  the  colon,  sigmoid,  and  rectum.  They  are  of 
stony  hardness  and  sausage  shape  and  show  concentric  rings  on 
section.  They  may  attain  considerable  size  and  even  cause  intestinal 
obstruction. 

Foreign  Bodies. — Bodies  which  have  been  swallowed  may  pass 
through  the  entire  bowel  and  be  passed  in  the  feces,  such  as  bones, 
coins,  marbles,  needles,  etc.  Concretions  of  shellac  have  been  found 
in  the  stools  of  patients  who  have  drunk  furniture  polish.  Hair- 
balls  may  be  found. 

Microscopic  Examination. — The  microscopic  examination  of 
the  feces  is  often  of  great  assistance  to  diagnosis.  For  examination 
for  amebae,  the  stool  should  be  kept  warm. 

1  "■--h.  Berliner  klin.  Wochensclir.,  1898,  No.  8. 


EXAMINATION    OF"   THE    FECES 


417 


To  diminish  the  disagreeable  odor  of  a  watery  stool,  place  it  in 
a  conic  glass  and  cover  it  with  a  layer  of  ether.  If  it  is  mushy  or 
firm,  it  can  be  spread  on  a  plate  and  covered  with  a  layer  of  spirits 
of  turpentine,  or  a  5  per  cent,  solution  of  carbolic  acid  or  thymol, 
or  4  per  cent,  formalin. 

Diarrheal  stools  may  be  examined  without  further  preparation. 

With  solid  fecal  matter,  a  small  piece  of  feces  ma}^  be  placed  on  a 
slide  and  mixed  with  a  drop  or  two  of  normal  salt  solution.  If  there 
is  odor,  a  i  per  cent,  formalin  solution  may  be  added.  The  findings 
depend  on  the  diet.  With  meat  diet,  no  vegetable  residue  is  found, 
and  vice  versa.  With  a  mixed  diet,  in  a  normal  stool,  there  will  be 
plant  cells,  the  remnants  of  various  vegetables  and  fruits,  no  starch 
granules,   meat-fibers  changed  beyond   recognition,   or  with   slight 


i 


// 


rTMMlW.MFW*W.>«U<3ITIV»MM|. 


Fig.  177. — General  view  of  the  feces:  a,  Epithelial  cells  and  leukocytes;  b, 
stone-cells;  c,  cuticular  formations;  d,  crystals  of  ammoniomagnesium  phosphate; 
e,  fat-crystals;  /,  yeast-fungi;  g,  Amoeba  coli;  h.  Trichomonas  intestinalis;  %, 
Cercomonas  intestinalis;  m,  ovum  of  ascaris;  n,  ovum  of  oxyuris;  o,  ovum  of 
trichocephalus;  p,  ovum  of  ankylostomum ;  q,  ovum  of  bothriocephalus;  r,  ovum 
of  Tsenia  saginata;  s,  ovum  of  Taenia  solium  (Jakob). 


striation  (Fig.  177).  More  commonly  they  appear  as  oval  yellow 
translucent  masses  with  a  high  degree  of  refractibility.  The  presence 
of  numerous  meat-fibers  striated  and  with  nuclei  is  pathologic, 
showing  deficient  pancreatic  digestion  (tryptic).  They  may  appear 
a'^-  spirals   (Fig.  178). 

Fat. — ^Fat  appears  microscopically  as  colorless  small  globules 
or  as  needle-shaped  crystals  (fatty  acids)  or  in  sheaves  (soaps).  The 
fatty  acids  disappear  when  heated  or  when  ether  is  added ;  soaps 
remain  unchanged.  Sudan  dye-stuff,  in  concentrated  alcoholic 
solution,  stains  plain  fat  bright  red,  while  crystals  of  fatty  acid  and 
the  soaps  remain  unchanged.  In  pathologic  conditions  these  forms 
of  fat  are  markedly  increased,  as  in  affections  of  the  liver,  pancreas, 
and  intestines.     Normally,  they  are  scanty. 


4i8 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


Crystals. — Oxalate  of  lime,  calcium  carbonate,  neutral  phosphate 
of  calcium,  and  ammonium  magnesium  phosphate  are  found  in 
normal  as  well  as  pathologic  feces  and  have  no  diagnostic  importance. 


Fig.  178. — a,  Spirals  of  undigested  meat-fibers  in  stool;  b,  pieces  of  bronchi. 

Bismuth,  if  administered,  occurs  as  dark  brown  or  nearly  black 
rhomboid  crystals.  Hematoidin  appears  in  rhombic  crystals  of 
orange  or  red  color,  shortly  after  intestinal  hemorrhage.     Charcot- 


Fig.  179. — Charcot-Leyden  crystals  (after  Riegel). 

Leyden  crystals  (Fig.  179)  are  fine  colorless,  pointed  octahedra. 
These  when  present  excite  the  suspicion  of  helminthiasis  (intestinal 
parasites),  and  their  persistence  after  removal  of  the  tenia  shows  the 


EXAMINATION    OF   THE    FECES 


419 


head  has  probably  not  been  removed.  They  occur  occasionally  in 
normal  stools  and  in  typhoid,  dysentery,  and  phthisis. 

Epithelium. — Epithelial  cells  when  present  in  large  numbers 
always  indicate  an  inflammatory  condition  of  some  part  of  the 
intestinal  tract.  Cylindric  epithelial  cells  are  found  in  abundance 
in  inflammation  of  the  intestinal  mucosa  (Fig.  180).  They  cause 
the  cloudy  appearance  of  the  mucus.  If  bile-stained  specimens  of 
epithelia  are  met  with,  the  small  intestine  is  involved.  Degenerative 
forms  without  nuclei  are  mostly  seen,  though  well  preser^^ed  cylindric 
or  goblet-cells  are  often  found. 

Red  blood-cells  are  rarely  obser\^ed  unless  hemorrhage  is  from  the 
colon  or  rectum,  as  in  dysentery.  Hemorrhage  higher  up  gives  a 
brownish-red  color  to  the  feces,  and  hematoidin  rhombic  crystals 
in  some  cases,  and  the  cells  cannot  be  recognized  microscopically. 


Fig.  180. — Chronic  intestinal  catarrh:  Fig.  181. — Intestinal  catarrh:    Con- 
Groups  of  epithelial  cells,  detritus,  some  siderable  mucus,  some  plant  cells,  mus- 
muscle  cells  partly  digested,  bacteria,  cle  cells,  and  fat  crystals. 
plant  cells,  and  yeast  cells. 

Pus  occurs  in  the  dejecta  in  ulcerative  processes  when  an  abscess 
communicates  with  the  bowel  or  in  dysentery.  It  presents  the 
usual  characteristics. 

Muciis  when  bile-stained  indicates  disease  of  the  small  intestine; 
and  if  colorless,  catarrh  of  the  large  intestine  or  lower  part  of  small 
intestine  is  present.  Mucus  also  occurs  with  mucous  colic,  in  which 
condition  no  catarrh  exists.  Mucus  is  thread-like  in  appearance, 
though  occasionally  amorphous  (Fig.  181).  Hyaline  particles  of 
vegetable  residue  must  not  be  mistaken  for  mucus.  lodin  stains  it 
blue.  Thionin  colors  it  reddish  violet  and  other  proteids  blue. 
■Mucus  has  no  definite  structure. 

Tiimor. — Fragments  of  tumor  may  rarely  be  found  in  the  feces 
and  its  character  determined  by  the  microscope. 

Microorganisms.-  —A  large  portion  of  the  stool  is  constituted  by 
bacteria,  as  already  mentioned.     Among  the  most  important  are  the 


420  DISEASES    O'P   THE   STOMACH   AND   INTESTINES 

Bacillus  coli,  Bacillus  lactis  aerogenes,  Bacillus  bifidus,  Bacillus 
aerogenes  capsulatus  (gas-forming),  and  Bacillus  putrificus. 

The  Bacillus  coli  is  of  importance  in  reference  to  the  indolic 
t3"pe,  and  the  Bacillus  aerogenes  capsulatus,  to  the  saccharobutyric 
type  of  intestinal  putrefaction.  The  Bacillus  lactis  aerogenes  causes 
fermentation  of  milk  and  the  production  of  lactic  acid. 

The  lactic  acid  producing  bacilU  are  held  to  be  antagonistic  to 
putrefactive  changes.  For  a  description  the  reader  is  referred  to 
any  work  on  Bacteriology.  Typhoid,  tubercle,  dysenteric,  and  the 
cholera  bacilli  are  the  chief  pathogenic  micro-organisms  found  in  the 
feces  which  are  of  interest  to  us. 

TESTING  THE   INTESTINAL  FUNCTIONS 

Boas  has  obtained  intestinal  juice  by  passing  the  stomach-tube 
into  the  empty  organ  and  massaging  the  region  of  the  liver,  thus 
forcing  the  juice  into  the  stomach.  Hemmeter  and  Kuhn  have 
passed  the  tube  directly.  These  procedures  are  uncertain  and  pos- 
sess no  advantages. 

Einhorn^  has  devised  a  new  method  of  obtaining  the  intestinal 
juice  by  means  of  a  duodenal  bucket.^  The  quantity  secured  (and 
it  is  not  always  obtained)  is  infinitesimally  small ;  there  is  the  possi- 
bility of  an  admixture  of  gastric  juice  and  saliva  during  withdrawal, 
and  the  procedure  requires  three  to  five  hours  or  even  longer.  It  does 
not  admit  of  the  thorough  technic  as  secured  by  Schmidt's  test  diet. 

The  same  holds  true  of  Einhorn's  bead  test.^  Testing  the  motor 
function  with  foreign  bodies  (beads)  is  not  a  proper  criterion;  the 
food  material  attached  to  each  bead  is  too  infinitesimally  small  in 
amount  to  test  the  digestive  capacity  for  an  average  diet;  it  may 
work  loose  from  the  beads,  in  which  event  it  could  not  be  recovered 
and  wrong  deductions  might  result.  There  is  a  slight  element  of  risk 
from  fish-bone  escaping  from  the  bead  and  damaging  the  mucosa. 

The  author  believes  the  stomach  functions  should  be  tested  sepa- 
rately, and  one  should  not  depend  on  the  connective-tissue  test  for 
the  stomach,  as  suggested  by  Schmidt. 

1  am  indebted  to  E.  E.  Smith,  of  New  York,  for  the  following 
description  of  the  tests  of  the  intestinal  functions: 

Tests  of  the  Intestinal  Functions. — The  determination  of  the 
functional  activity  of  the  stomach  is  made  with  relative  ease,  com- 
pared to  the  similar  examination  of  the  intestines.  Correspondingly, 
methods  for  such  determination  have  long  been  applied  to  the  former 

*  New  York  Medical  Journal,  June  20,  1908. 

2  Einhorn  has  recently  suggested  passing  a  soft  tube  along  the  duodenal  bucket 
cord  (on  the  principle  of  Gouley's  tunnel  sound  along  the  filiform  bougie),  and 
then  aspirating  the  intestinal  contents  with  a  bulb.  Farr  (Jour.  Amer.  Med. 
Assoc,  Dec.  11,  1909)  describes  Boldireff's  oil  test  meal  to  secure  trypsin  in  the 
gastric  contents,  and  the  tests  of  Mett,  Yolhard,  and  Gross.  These  tests  are  com- 
])licated.     Trypsin  is  not  always  secured. 

3  Med.  Record,  Feb  10,  1906:  Ibid.,  Oct.  26,  1907;  Journal  Am.  Med.  Associa- 
tion, Feb    2,  1907,  Therapeutic  Gazette,  Jan.  15,  1908. 


TESTING   THE    INTESTINAL   FUNCTIONS  42 1 

organ,  while  they  have  recently  found  application  to  the  latter;  and 
even  now  the  diagnostic  determination  of  intestinal  function  by 
exact  methods  is  only  in  its  infancy.  The  problems  presented  are 
essentially  these : 

(a)  Is  intestinal  secretion,  including  pancreatic  and  biliary 
secretions,  normal  in  quality  and  quantity  ?  (b)  Is  intestinal  absorp- 
tion normal  ?  (c)  Is  the  intestinal  motor  activity  normal  ?  If  not, 
in  what  respect  is  each  of  these  processes  abnormal? 

The  investigation  of  these  problems  is  made  by  the  use  of  a  test 
diet.  While  in  the  case  of  the  stomach  the  diet  is  relatively  simple 
and  the  digestive  mixture  withdrawn  for  examination  within  a  few 
hours,  in  the  case  of  the  intestines  only  inferences  as  to  the  intestinal 
contents  may  be  reached,  and  then  indirectly  from  the  conditions 
affecting  the  bowel  contents  after  they  have  been  ejected,  perhaps  in 
one  or  several  days.  The  feces  corresponding  to  the  test  diet  may 
be  indicated  by  a  material  administered  for  the  purpose,  usually 
soot  in  capsules.  No.  00  hard  gelatin  capsules  filled  with  soot  accom- 
plishing this  purpose;  or  carmin  may  be  used,  0.3  gm.  (5  gr.),  in  a 
capsule.  Either  of  these  is  administered  at  the  beginning  of  the 
first  meal  of  the  test  diet.  The  subsequent  appearance  of  a  black  or 
red  stool  indicates  that  the  intestinal  contents  corresponding  to  the 
special  diet  are  being  ejected. 

The  administration  of  a  special  substance  to  mark  the  stools  is 
in  a  majority  of  instances  not  absolutely  necessary,  the  diet  being  of 
a  nature  that  gives  rise  to  a  stool  sufficiently  distinctive  for  recogni- 
tion. Until  the  observer  is  familiar  with  the  examination,  it  is 
advisable  to  employ  one  of  the  substances  mentioned. 

The  test  diet  to  be  employed  is  selected  to  meet  the  requirement 
that  it  shall  present  a  sufficient  quantity  of  all  classes  of  food  stuffs 
to  test  the  digestive  capacity,  that  the  digestive  processes  shall  not  be 
unduly  anticipated  in  the  preparation  of  the  food,  and  that  very  little 
food  residue  shall  be  present  in  the  ejected  bowel  contents.  Naturalh', 
the  stomach  plays  its  usual  part,  so  that  the  test  is  not  limited  to 
the  intestinal  tract  proper,  but  applies  to  alimentation  as  a  whole. 

The  test  diet  made  use  of  is  a  modification  of  the  original  Schmidt- 
Strasburger  diets.  Instead  of  three  diets,  as  were  originally  employed 
in  connection  with  the  fermentation  test  of  these  observers,  one  diet 
is  now  advocated  which  presents  the  conditions  essential  for  the  meat 
test.     This  diet,  as  recently  described  by  Schmidt,  is  as  follows: 

In  the  Morning. — 0.5  liter  milk  or,  if  milk  does  not  agree,  0.5  liter  cocoa  (pre- 
pared from  20  gm.  cocoa  powder,  10  gm.  sugar,  400  gm.  water,  and  100  gm. 
milk),  to  this  add  50  gm.  Zwieback. 

In  the  Forenoon. — 0.5  liter  oatmeal  gruel — made  frorn  40  gm.  oatmeal,  lo  gm. 
butter,  100  gm.  milk,  300  gm.  water,  i  egg — (strained). 

At  Noon. — 125  gm.  chopped  beef  (raw  weight),  broiled  rare  with  20  gm.  of  butter, 
so  that  the  interior  will  remain  raw;  to  this  add  250  gm.  potato  broth  (made 
of  iQO  gm.  mashed  yiotatoes,  100  gm.  milk,  and  10  gm.  butter). 

In  the  Afternoon. — As  in  the  morning. 

In  the  Evening. — As  in  the  forenoon. 


422   •  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

This  diet  consists  of: 

1.5  liters  milk, 
100  gm.  Zwieback, 
2  eggs, 
50  gm.  butter, 
125  gm.  beef, 

190  gm.  potatoes  and  gruel  of 
80  gm.  oatmeal. 

It  contains  about: 

102  gm.  albumin, 
III  gm.  fat, 

191  gm.  carbohydrates,  or  a  total  of  2234  calories  fraw  calories). 

The  test  is  generally  given  for  three  days,  sometimes  longer; 
at  any  rate  until  a  stool  is  obtained,  which  comes  with  certainty 
from  this  diet. 

Steele  advocates  an  arrangement  of  the  diet  to  conform  to 
American  dietary  habits,  which  still  maintains  the  essential  features 
of  the  above.     It  consists  of: 

2f  pints  milk, 

3  ounces  well-dried  toast, 

2  eggs, 

I J  ounces  butter, 

J  pound  tender  rare  steak, 

6  ounces  mashed  boiled  white  potato,  and  gruel  made  from 

25  ounces  ordinary  oatmeal, 

J  ounce  sugar. 

This  may  be  given  somewhat  as  follows: 

Breakfast. — 2  eggs,  one-third  of  the  amount  of  toast  and  butter,  2  glasses  of  milk, 

oatmeal,  and  sugar. 
Dinner. — The  steak  and  potato,  one-third  of  the  amount  of  toast  and  butter, 

\\  glasses  of  milk. 
Supper. — 2  glasses  of  milk,  remainder  of  toast  and  butter. 

For  the  collection  of  the  stools,  where  they  are  not  to  be  trans- 
ported for  any  considerable  distance,  an  ordinary  tin  basin  of  24-oz. 
capacity  ser\^es  well  for  a  receptacle,  as  suggested  by  Prof.  L.  B. 
Mendel.  This  may  be  supplied  with  a  cover,  consisting  of  a  cake 
tin  of  appropriate  size;  or,  where  this  is  not  readily  provided,  a  small 
pie  tin  may  be  used.  This  outfit  is  inexpensive  (8  cents),  adequate, 
and  where  a  considerable  number  are  to  be  kept,  may  be  advanta- 
geously stacked.  ^loreover,  where  the  stools  are  to  be  weighed  and 
dried  for  exact  quantitative  analysis,  this  may  be  directly  done  in 
the  weighed  basins,  thus  avoiding  the  transfer  of  the  specimens. 

If  the  feces  are  to  be  transported  for  any  considerable  distance, 
a  pint  glass  jar  (with  patent  airtight  top)  sen.-es  admirably  for  the 
collection.  .The  specimen  may  be  hermetically  sealed.  If  trans- 
ported in  ordinary  wide-mouthed  bottles,  the  stoppers  should  be 


TESTING   THE    INTESTIXAL   FUNCTIONS  423 

tied  on,  as  gas  formation  is  quite  likely  to  produce  sufficient  pressure 
to  force  out  any  stopper  not  securely  fastened. 

The  characteristics  of  the  test  diet  stool,  aside  from  the  coloration 
given  by  the  special  marking  substance  administered,  are  the  light 
brown  color  and  uniform  consistency.  It  usually  appears  at  the 
second  or  third  defecation  after  the  beginning  of  the  test  diet. 

The  period  of  time  required  for  the  passage  of  food  through  the 
entire  alimentary  tract  is  of  importance  and  is  readily  obser\'ed. 
Normally  it  takes  about  twenty-four  hours.  It  is  not  necessarily, 
though  it  is  commonly,  related  to  the  frequency  of  defecation.  In 
some  cases  the  stool  appears  with  regularity  and  is  fairly  copious, 
vet  the  patient  suffers  from  fecal  accumulation — a  latent  constipa- 
tion. The  period  of  passage  may  suggest  the  seat  of  the  intestinal 
disturbance  in  diarrhea,  since  it  is  only  decidedly  increased  when 
the  cause  is  high  up.  Strauss  has  shown  that  chronic  colitis  maybe 
accompanied  by  several  watery  movements  a  day  with  a  normal 
period  of  passage.  The  examination  of  the  collected  stool  should  be 
'  made  while  the  feces  are  perfectly  fresh. 

Macroscopic  Examination. — This  is  the  most  important  part  of 
the  procedure.  Experience  with  this  part  of  the  investigation  may 
enable  the  observer  to  at  once  recognize  some  defect  in  alimenta- 
tion. 

Note  the  consistence,  color,  and  odor.  Inspect  the  surface  of 
the  formed  stool  for  morbid  products,  notably  for  pus,  blood,  and 
mucus,  which  are  to  be  removed  for  microscopic  and  bacteriologic 
examination.  Bits  of  tissue  from  some  diseased  area  may  also  be 
sought  for,  but  their  occurrence  is  so  unusual  that  it  is  exceptional 
when  they  are  found. 

The  mass  of  feces  is  then  well  mixed,  for  which  procedure  a  wooden 
or  tin-plate  spoon  is  useful;  and  a  piece  the  size  of  a  walnut  trans- 
ferred to  a  mortar,  in  which  it  is  thoroughly  but  not  forcibly  ground 
with  distilled  water  added  gradually  until  the  whole  is  of  a  uniform 
fluid  consistency  and  no  small  masses  of  fecal  matter  remain.  The 
fluid  feces  is  then  examined  in  thin  layers,  conveniently  in  a  Petri 
or  similar  larger  dish,  against  a  black  background  with  the  naked 
eye,  or  low-power  magnifying  glass,  for  all  elements  that  may  be 
differentiated.  In  normal  digestion  only  a  few  brown  points  smaller 
than  pin-heads  will  appear,  these  consisting  of  chaffy  remains  of 
oatmeal  gruel  and  remains  of  cocoa,  if  this  latter  has  been  taken. 
Under  pathologic  conditions,  there  may  be  present: 

1.  :\Iucus,  which  appears  usually  as  larger  or  smaller,  soft,  glossy, 
translucent  flakes,  often  bile  stained;  infrequently,  when  from  the 
large  intestine,  white  or  brown,  with  a  gummy  or  almost  leathery 
hardness. 

2.  Pus,  blood,  parasites,  stones,  and  other  foreign  bodies. 

3.  Connective  tissue  and  tendons,  distinguished  by  their  whitish- 
yellow  color,  thread-like  appearance,  and  solid  consistence. 


424  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

4.  Muscular  tissue,  chiefly  in  very  small,  brown  colored  rods, 
like  splinters  of  wood. 

5.  Potato,  appearing  like  boiled  tapioca  grains,  readily  confused 
with  flakes  of  mucus.     The  distinction  is  made  with  the  microscope. 

6.  Large  crystals  of  ammoniomagnesium  phosphate,  which 
grate  when  the  specimen  is  ground. 

Microscopic  Examination. — This  serves  chiefly  to  complete  the 
gross  inspection.  In  addition  to  the  preparations  of  material  selected 
during  the  macroscopic  examination,  three  slide  preparations  are 
made.  The  first  consists  merely  of  a  drop  of  the  liquefied  stool  under 
the  cover-glass.  The  second,  a  drop  of  the  liquefied  stool  mixed 
with  a  drop  of  acetic  acid,  heated  to  the  beginning  of  boiling  and 
covered  with  a  cover-glass.  The  third  consists  of  a  drop  of  the 
liquefied  stool  mixed  with  potassium  iodid  solution  of  iodin  and 
covered  with  a  cover-glass. 

Inspection  of  the  first  slide  preparation  by  the  aid  of  the  micro- 
scope, using  a  high,  dry  lens,  reveals  finely  divided  material  consisting 
of  bacteria  and  mostly  unrecognizable  detritus,  in  which  are 
imbedded : 

(a)  Isolated  fragments  of  muscle-fibers,  usually  bile  stained, 
partially  digested,  but  occasionally  with  the  transverse  striations 
recognizable. 

ih)  Larger  or  smaller  yellow  crystals  of  the  alkali  earth  salts  of 
the  fatty  acids. 

(c)  Colorless  soaps. 

{d)  Isolated  potato  cells,  without  distinguishable  contents. 

(e)  Particles  of  oatmeal  and  cocoa  shells,  where  the  latter  is 
taken  instead  of  milk. 

The  second  slide  gives  a  general  idea  of  the  fat  present  in  the 
stool.  While  hot,  the  fatty  acids,  liberated  in  the  acetic  acid,  appear 
as  drops;  on  cooling,  these  congeal  to  small  needle-like  crystals. 

In  the  third  preparation  potato  remains  have  a  violet  color, 
while  isolated  fungus  spores  (Clostridium  butyricum)  may  appear 
blue. 

The  pathologic  findings  which  the  slide  may  present,  in  addition 
to  those  enumerated  under  the  macroscopic  examination,  are: 

Slide  I. — Muscle  fragments  in  greater  number  and  better  state  of  preservation, 
particularly  wiih  retained  nuclei;  drops  of  neutral  fat;  needles  of  fatty 
acids  and  soaps;  many  groups  of  potato  cells. 

Slide  II. — Massive  fatty  acid  drops  and  crystals. 

Slide  III. — Blue  starch  grains,  free  or  in  the  potato  cells;  oatmeal  cells;  any  con- 
siderable number  of  blue-staining  fungus  spores  or  thread-like  bacteria. 

Bacteriologic  Examination. — The  recognition  of  the  tubercle, 
typhoid,  Shiga,  or  cholera  bacillus  calls  for  technic  which  will  be 
found  described  in  special  treatises.  The  selection  of  material  to  be 
examined  for  tubercle  bacilli  is  best  made  from  the  surface  of  formed 


TESTING    THE    INTESTINAL    FUNCTIONS  425 

stools,  since  in  soft  movements  morbid  products  from  the  diseased 
area  will  be  so  mixed  with  the  feces  as  to  easily  escape  detection. 

For  amebae  a  saline^  should  be  given  and  the  warm  liquid  stool 
examined.  Mention  has  already  been  made  of  the  detection  of  bac- 
teria and  fungi  which  are  colored  blue  by  iodin  (granulose  reaction). 

Procedures  that  yield  information  of  considerable  value  in  the 
less  specific  forms  of  intestinal  infection  have  recently  been  advocated 
by  Herter.  Of  first  importance  is  the  preparation  of  smears  of  the 
mixed  stools  on  microscopic  slides,  stained  b}"  the  Gram  method. 
The  relative  number  of  Gram-positive  bacteria,  as  also  their  character, 
is  of  diagnostic  value,  since  they  are  relatively  few  in  health  and  in 
meat-free  diet,  while  they  are  increased  in  some  diseased  conditions 
and  when  notable  quantities  of  meat  are  eaten.  Not  only  is  it  of 
value  to  note  the  actual  increase,  but  the  potential.  The  latter  is 
determined  by  the  observation  of  the  relative  number  of  Gram- 
positive  bacteria  in  the  residues  in  the  sugar-bouillon  tubes  (see 
below),  a  predominance  of  Gram-positive  bacteria  indicating  a 
pathologic   tendency   of  the  fecal   flora. 

The  sugar-bouillon  tubes  just  mentioned  are  ordinary  fermenta- 
tion tubes,  containing  i  per  cent,  lactose-bouillon,  i  per  cent,  glucose- 
bouillon,  and  I  per  cent,  saccharose-bouillon  respectively. 

Normally,  little  fermentation  occurs  when  the  tubes  have  been 
incubated  at  37°  C  for  twenty  to  twenty-two  hours.  Active  gas 
production,  so  that  it  accumulates  to  the  extent  of  more  than  one- 
third  of  the  tube  capacity,  is  most  frequently  due  to  the  predominance 
of  a  bacillus  identical  with  or  allied  to  the  Gram-positive  Bacillus 
aerogenes  capsulatus,  the  growth  of  which  replaces  the  Bacillus 
coli  communis,  the  normal  intestinal  inhabitant. 

Chemic  Examination. — The  cheinic  reaction  is  best  determined 
by  smearing  one  side  only  of  moistened  red  and  blue  litmus-paper 
with  the  diluted  (see  Macroscopic  Examination)  fecal  matter.  After 
some  time  the  reaction  is  noted  on  the  opposite  side.  It  is  usually 
amphoteric,  feebly  acid,  or  alkaline. 

The  sublimate  test  for  unchanged  bile-pigment  is  performed  by  add- 
ing some  of  the  diluted  fecal  matter  to  a  considerable  excess  of  strong 
solution  of  bichlorid  of  mercury,  allowing  the  mixture  to  stand  over 
night.  The  normal  feces  are  colored  red  ;  more  intensely,  the  fresher 
and  less  decomposed  the  excrement.  Herter  points  out  that  this  red 
coloration  may  be  pathologically  increased  in  excessive  saccharobuty- 
ric  putrefaction.  In  the  presence  of  bilirtibin,  a  green  coloration  is  pro- 
duced. This,  even  to  the  extent  of  microscopically  small  particles,  is 
pathologic.  A  negative  sublimate  test  suggests  suppression  of  bile ;  an 
incomplete  test  with  fresh  stools, abnormal  processes  of  decomposition. 

The  fermentation  test  of  Schmidt  and  Strasburger  for  fermentable 
carbohydrate  or  putrescible  proteid  is  performed  in  the  Strasburger 
fermentation  tube  (Fig.  182). 

^  Magnesium  sulphate  is  an  excellent  saline  cathartic  to  employ. 


426 


DISEASES   Olf   THE   STOMACH  AND   INTESTINES 


V 


A  5-gram  portion  of  the  well-mixed,  undiluted,  fresh  excrement, 
or  proportionally  more  of  the  thinner  material,  is  well  mixed  with 
sterile  water;  the  chemic  reaction  noted;  and  then  the  mixture  is 
introduced  into  the  lower  vessel  of  the  apparatus. 

The   bottle   is   entirely  filled   with   water   and   stoppered,   with 
exclusion  of  air.     The  adjacent  upper  tube  is  filled  or  nearly  filled 
with  water,  while  the  distal  tube  remains  empty.     The  apparatus  is 
incubated  at  37°  C.  for  twenty-four  hours. 

The  extent  of  gas  formation  is  indicated  by 
the  amount  of  water  displaced  by  the  gas  from  b' 
and  which  accumulates  in  the  distal  tube  c'. 
Normally,  there  is  practically  no  gas  formation, 
and  the  chemic  reaction  of  the  fecal  mixture 
remains  about  unchanged.  Gas  production  to 
such  an  extent  as  to  introduce  an  amount  of 
water  into  the  distal  tube  equal  to  one-third 
its  capacity  is  pathologic.  If  coincidently  with 
the  gas  production  the  chemic  reaction  has  de- 
veloped a  decidedly  increased  acidity,  the  gas 
production  is  due  to  carbohydrate  fermenta- 
tion ;  if  alkalinity,  albuminous  putrefaction  has 
occurred.  When  the  proximal  tube  is  opened  it, 
gives  off  a  butyric  acid  odor  in  the  former  case 
and  a  putrefactive  odor  in  the  latter.  The 
color  of  fermenting  feces  is  generally  brighter; 
of  putrefying  feces,  darker.  The  test  is  more 
especially  applicable  to  the  test  diet  stools. 

If  the  condition  approximates  the  normal,  a 
further  test  should  be  carried  out  for  accuracy. 
In  such  event,  the  patient  is  placed  on  a  diet 
which  differs  only  from  the  first  in  the  absence 
of  meat  and  potato.  If  there  is  still  a  positive 
result,  the  diagnosis  of  "fermentative dyspepsia" 
is  justifiable. 

Putrefactive  Products. — Tests  for  indol  and  skatol  may  be  applied 
to  the  distillate,  using  10  gm.  of  the  feces  mixed  with  120  cc.  of  water, 
the  whole  made  alkaline,  a  bit  of  paraffin  added  to  prevent  frothing, 
and  the  first  50  cc.  collected. 

A  suitable  apparatus  for  conducting  the  process  consists  of  a 
500-CC.  capacity  long-neck  Kjeldahl  digestion  .flask  connected  with 
a  I^iebig  condenser.  Distillation  with  steam  is  sometimes  advantage- 
ous; 10  cc.  of  the  distillate  is  rendered  slightly  alkaline  with  sodium 
or  potassium  hydroxid  and  an  excess  of  a  fresh  solution  of  beta- 
naphthaquinone-sodium-monosulphanate  added.  The  substance, 
in  the  course  of  a  few  minutes,  reacts  almost  completely  with  the 
indol  present,  but  not  with  the  skatol;  with  the  resulting  formation 
of  a  bluish  precipitate  with  much  indol,  and  a  mere  coloration  of  the 


Fig.    182.  —  Stras- 
burger's  tube. 


TESTING  THE   INTESTINAL   FUNCTIONS  427 

solution  with  little.  If  more  than  a  trace  is  present,  the  reaction  is 
conducted  with  the  remaining  40  cc.  of  the  distillate,  the  indol- 
naphthaquinone  compound  removed  from  the  whole  by  filtration, 
and  from  the  portion  remaining  in  solution  by  distillation,  after 
acidifying. 

The  distillate  containing  the  skatol,  if  necessary,  freed  from  indol 
as  described,  is  tested  by  the  use  of  a  well-marked  excess  of  dimethyl- 
amido-benzaldehyd  (Ehrlich's  aldehyd),  being  boiled  with  a  5  per 
cent,  solution  in  10  per  cent,  sulphuric  acid.  Dilute  hydrochloric 
acid  is  added  to  the  point  of  the  production  of  the  maximum  color 
intensity  and  the  mixture  rapidly  cooled.  The  presence  of  skatol 
is  indicated  by  the  blue  coloration.  The  color  may  with  advantage 
be  extracted  with  chloroform. 

If  the  process  described  is  to  be  conducted  quantitatively,  25  gm. 
of  feces  should  be  employed,  and  distillation  continued  till  the 
distillate  is  free  from  substances  reacting  with  the  above  reagents, 
the  color  shaken  out  with  known  volumes  of  chloroform,  and  the 
depth  of  color  compared  by  the  aid  of  the  Duboscq  colorimeter,  with 
a  similar  chloroform  extract  obtained  by  starting  with  solutions  of 
known  strength  of  indol  and  skatol  respectively. 

REFERENCES 

1.  Herter,  C.  A.,  Bacterial  Infections  of  the  Digestive  Tract,  1907. 

2.  Herter,  C.  A.,  and  Foster,  M.  Louise,  Journal  of  Biol.Chem.,  i,  p.  257;  ii, 

p.  267. 

3.  Schmidt,  A.,  translated  by  C.  D.  Aaron,  The  Test  Diet  in  Intestinal  Dis- 

eases, vol.  Ixxvii,  igo6. 

4.  Steele,  J.  Dutton,  Medical  News,  1905,  p.  1158,  vol.  Ixxvii. 

Results. — In  interpretation  of  results,  we  have  to  consider  both 
the  occurrence  of  pathologic  admixtures  and  an  increase  of  the  con- 
stituents from  the  test  diet. 

A  thin  coating  of  mucus  is  normally  collected  by  the  hardened 
fecal  matter.  Otherwise  the  appearance  of  this  product  indicates 
catarrh  of  the  mucosa,  the  mucus  containing  many  cellular  elements. 
An  exception  is  the  overproduction  of  mucus  in  colica  mucosa,  with 
cellular  elements  less  abundant  and  with  the  striking  consistence. 

Pus,  blood,  masses  of  epithelia  from  the  mucosa,  and  similar 
elements  carry  the  pathologic  significance  of  these  products,  and 
require  investigation  and  interpretation,  as  when  found  elsewhere. 

Considering  an  increase  of  the  constitutents  of  the  test  diet,  a 
distinct  connective-tissue  increase  indicates  deficient  gastric^  diges- 
tion. An  excessive  quantity  of  meat-fibers  points  to  deficient  proteid 
digestion  in  the  small  intestine.  The  albumin  fermentation  (putre- 
factive) test  further  indicates  increased  proteid  in  stools,  frequently 
derived  from  pathologic  secretions,  probably  associated  with  an 
abnormal  putrefactive  flora.  The  bacteriologic  examination,  espec- 
ially as  to  fermenting  and  Gram-positive  bacteria,  is  of  value  along 
1  The  author  advocates  a  separate  test  of  the  gastric  functions. 


42  8  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

these  lines.  Also  tests  for  putrefactive  products,  if  increased  activity 
in  this  direction  in  the  stool  itself  is  to  be  investigated. 

Starch  granules,  revealed  microscopically,  show  deficient  starch 
digestion  in  the  intestines,  due  either  to  rapid  passage  of  the  contents 
or  disturbed  secretion.  Defective  carbohydrate  digestion  is  also 
indicated  by  an  abnormal  carbohydrate  fermentation  test. 

Only  a  considerable  increase  of  fat  is  pathologic.  Such  a  stool  is 
indicated  by  the  quantity  of  the  stool  itself,  the  light  (whitish)  color, 
and  a  marked  acid  reaction,  as  well  as  by  the  microscopic  findings. 
A  deficient  flow  of  bile  or  of  pancreatic  secretion  is  the  usual  cause; 
in  the  former  case  the  stool  not  containing  pigment  (sublimate  test) ; 
in  the  latter  showing  an  associated  increase  of  meat-fibers,  frequently 
with  retained  nuclei.  Functional  disturbances  of  fat  digestion  are 
said  to  occur,  but  other  possibilities  must  be  excluded  in  reaching  this 
diagnosis. 

MECHANICAL  PROCEDURES 

The  Enema  ;  Intestinal  Irrigation  ;  Proctoclysis. — For  injection 
into  or  irrigation  of  the  intestines  there  are  four  methods,  all  of 
which  have  their  special  applications.     They  are : 

1.  The  enema. 

2.  Irrigation  with  a  single  tube. 

3.  Irrigation  with  a  double-current  tube  or  with  two  tubes. 

4.  Proctoclysis,  the  drop  method  of  injection. 

Uses  of  irrigations  or  enemata  are  as  follows :  The  local  treatment 
of  diseased  conditions,  as  of  catarrhal  colitis. 

The  relief  of  congestion  or  acute  inflammation,  as  of  the  rectum 
or  prostate. 

The  relief  of  pain  and  irritability,  as  in  spasm  of  the  sphincter. 

The  absorption  of  inflammatory  products,  as  of  postuterine  adhe- 
sions. 

To  replace  the  loss  of  fluid  in  the  body,  as  in  cholera. 

To  dilute  the  poison  of  disease,  as  in  uremia. 

To  increase  the  flow  of  blood  to  a  part,  as  in  insufiicient  men- 
struation. 

To  check  hemorrhage  (extreme  cold  or  heat).  Locally,  as  in 
bleeding  ulcers  of  the  rectum;  in  an  adjacent  organ,  as  in  uterine 
hemorrhage. 

Reflex  effects  through  the  sympathetic  ganglia,  on  the  circulator v 
apparatus,  on  the  secretions,  as  a  tonic  stimulant,  and  the  revulsive 
effects.  On  the  circulatory  apparatus,  as  in  shock.  On  the  secre- 
tions, as  in  the  production  of  sweating,  bowel  action,  and  urinary 
secretion  in  uremia.  As  a  tonic  stimulant,  as  by  use  of  the  alternate 
hot  and  cold  douche  in  diminution  of  erectile  power.  The  revulsive 
effect,  as  the  production  of  bowel  action  in  apoplexy.  The  reflex 
effect  on  a  distant  organ,  as  from  enemata  in  jaundice. 

The  effect  on  the  heat  centers — the  temperature  can  be  raised 


MECHANICAL   PROCEDURES 


429 


in  shock  by  hot  irrigation,  or  lowered  in  fever  by  cold  irrigation  or  by 
enemata. 

Simple  cleanliness,  removing  undigested  food  products,  and 
preventing  auto-intoxication. 

Antispasmodic,  as  by  relieving  spasm  in  colic. 

Mechanical,  as  in  intussusception. 

Water  as  a  vehicle — the  nutritive  enema. 

Physiologic  Experiments. — In  a  series  of  experiments  at  Columbia 
University  some  years  ago  the  author  demonstrated  on  animals 
(Fig.  183),  and  latei  clinically,  that  enteroclysis  at  110°  to  120°  F. 
best  stimulated  the  heart  in  shock;  that  renal  secretion  undergoes 
a  double  cycle  of  increase  from  enteroclysis  at  high  temperatures 


Fig.  183. — Method  of  performing  physiologic  experiments. 

(110°  to  120°  F.),  both  from  intestinal  absorption  and  from  the 
increased  blood  flow  through  the  kidney;  while  with  lower  temper- 
atures the  increase  is  merely  from  intestinal  absorption. 

Normal  saline  solution  has  a  specific  effect  in  increasing  renal 
secretion.  Cold  irrigations  first  stimulate,  then  depress.  Body  and 
blood  temperature  are  increased  by  hot  irrigations  and  diminished 
by  cold. 

These  experiments^  were  completel}^  reported. 

I.  Enema. — The  enema  may  be  high  with  a  colon-tube  (Fig.  184), 
which  should  be  thoroughly  lubricated  and  the  water  should  flow 
while  inserting.  It  should  be  administered  with  the  patient  on  the 
left  side,^  or  for  high  injection  in   the  knee-elbow  posture,  when  a 

1  Enteroclysis,  Hypodermoclysis,  and  Infusion,  Kemp;  Hydrotherapy,  S. 
Baruch;  Enteroclysis,  Reference  Hand-book  of  the  Medical  Sciences,  1900. 

2  The  dorsal  position,  with  the  hips  elevated,  can  be  employed. 


430 


DISEASES    OF   THE    STOMACH   AND    INTESTINES 


high  enema  can  thus  be  given  with  a  short  tip.     I  prefer  never  to 
give  more  than  i  to  i^  quarts  (liters). 


Fig.  184. — Colon-tube. 

Milder  medicated  solutions  can  be  employed  in  this  way.  The 
low  enema  is  of  more  value  for  low  impaction  or  to  relieve  local 
irritation  in  the  rectum  or  adjacent  organs. 

2.  Irrigation  with  a  Single  Tube. — There  are  four  modifications 
of  this  method : 


Fig.  185. — Lee's  cholera  table. 

(a)  A  colon-tube  is  inserted  into  the  bowel,  a  funnel  attached, 
and  by  raising  and  lowering  the  funnel,  the  bowel  is  washed  out- 

(6)  A  fountain  syringe  can  be  attached  to  the  colon-tube,  and 
when  sufficient  fluid  has  flowed  in  the  fountain  syringe  the  con- 
nection is  detached  and  the  fluid  flows  out  through  the  colon- 
tube. 


MECHANICAL    PROCEDURES 


431 


(c)  The   patient   can   void   the  fluid   around   the   colon-tube   or 
catheter  during  irrigation.     This  is  the  method  usually  employed 


Fig.  186. — Kemp's  flexible  recurrent  rectal  irrigator. 

with  infants.  Elmer  Lee  carried  out  this  technic  at  the  cholera 
stations  (Fig.  185).  An  irrigating  jar  may  be  substituted  for  the 
rubber  bag. 


Fig.  187. — Kemp's  glass  rectal  irrigator  (recurrent).      Cork  opening    above  for 

cleansing. 

(d)  A  glass  Y  is  attached  to  the  colon-tube,  as  in  lavage  of  the 
stomach ;  one  branch  is  connected  with  the  fountain  syringe,  the  other 


Fig.  188. — Kemp's  rectal  irrigator. 
All  metal  tube. 


Fig.  189. — Electric  attachment  for 
electro-enteroclysis.  Hard-rubber  tube 
with  metal  center. 


is   to   a   carry-off   tube.     By   alternately   pinching  the    soft-rubber 
outflow  and  inflow  tubes  the  bowel  can  be  irrigated. 


432 


DISEASES    OF   THE   STOMACH   AND   INTESTINES 


3.  Double-current  Irrigation  with  Two  Tubes  or  a  Recurrent  Tube. — 
Advantages. — The  quantity  of  the  fluid  is  under  the  control  of  the 


Fig.  190. — Kemp's  tube  (ready  for  cleansing).     Hard  rubber  with  metal  center. 


Fig.  191. — Enteroclysis  (double  current).     Patient  in  dorsal  position  on  bed-pan. 

Operator,  since  it  can  be  regulated  by  manipulation  of  the  outflow 
and  inflow  tubes. 

The  labor  is  placed  upon  the  operator  and  not  upon  the  patient, 


MECHANICAL    PROCEDURES 


433 


and  there  is  no  straining  to  overcome  the  resistance  of  the  sphincter. 
The  straining  of  self-evacuation  is  avoided,  and  mere  mechanical 
cleansing  of  the  bowel  is  employed.  The  temperature  of  the  fluid 
entering  the  bowel  can  be  kept  constant. 

Tympanites  is   relieved   best  by   this   method,   the   return    flow 
carries  off  the  gas  bv  suction.     With  the  enema  the  gas  frequently 


Fig.  192. — Enteroclysis  fdouble  current).      Patient  in  Sims'  position. 

collects  in  the  intestines  behind  the  injection  and  it  is  often  impossible 
to  exert  sufficient  force  to  expel  it  with  the  enema. 

Two  catheters  or  two  small  rectal  tubes  passed  through  a  perineal 
pad  can  be  improvised  for  this  purpose.  The  illustrations  of  the 
author's  tubes  are  shown  (Figs.  186-190).  They  are  readily  under- 
stood. J.  P.  Tuttle's,  Hemmeter's,  and  various  recurrent  rectal 
tubes  are  described  by  the  author  in  his  manual  "  Enteroclysis." 
The  hard-rubber  tube  with  metal  center  is  the  best.  All  metal 
tubes  are  good  for  hospital  work. 

28 


434 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


The  flexible  tube  is  excellent  for  sensitive  cases  or  for  young 
children. 

To  the  middle  tube  of  the  irrigator  is  attached  the  tube  of  the 
fountain  syringe;  to  the  curved  tube  the  outflow  soft-rubber  tubing 
is  fastened.  This  last  must  be  pinched,  as  it  is  the  larger,  in  order 
that  fluid  may  pass  up  the  bowel.  By  alternately  pinching  the  in- 
flow and  outflow  the  quantity  of  fluid  may  be  regulated. 


Fig    193. — Enteroclysis  (double  current)  without  the  bed-pan. 

Position  of  the  Patient. — Elevation  of  the  hips  is  the  important 
feature,  not  the  length  of  the  tube.  The  different  positions  of  the 
patieiits  are  illustrated  and  are  readily  understood  (Figs.  191-195). 

Method  by  Rotation. — Patient  is  placed  on  the  left  side  with  the 
hips  elevated,  and  the  descending  colon  is  irrigated. 

Rotate  the  patient  gradually  to  the  dorsal  position,  and  then  to 
the  right  side,  with  the  hips  elevated ;  the  return  tube  being  pinched. 
About  1 5  pints  to  1  quart  (750  to  1000  cc.)  of  fluid  are  allowed  to 
run  into  the  bowel. 


MECHANICAL   PROCEDURES 


435 


The  shoulders  are  then  elevated  to  above  the  level  of  the  hips, 
the  patient  being  still  on  the  right  side.  This  is  to  make  the  fluid 
gravitate  into  the  caput  coli. 

The  shoulders  are  then  depressed  to  below  the  hip  level,  the 
patient  on  the  right  side ;  he  is  then  gradually  rotated  to  the  dorsal 
position  and  then  to  the  left  side,  and  as  a  final  step  the  shoulders  are 
elevated,  etc.  In  other  words,  the  process  is  reversed.  The  return 
tube  is  then  released  and  the  fluid  is  allowed  to  escape. 


Fig.  194.- 


-Enteroclysis  (double  current).     Patient  in  semi-oblique  position,  as  in 
pulmonary  edema,  etc.,  when  dorsal  position  is  impossible. 


I  employ  tnost  frequently  the  dorsal  position  without  the  bed-pan. 

Temperature  of  the  solution  depends  upon  the  conditions  of  its 
employment,  an  average  of  101°  to  105°  F.  in  intestinal  catarrh; 
at  110°  F.  in  typhoid  for  an  additional  eliminative  eff"ect,  and  for 
shock  and  uremia  at  115°  to  120°  F. 

Solutions  Employed. — Flaxseed  tea  {2  drams — 8.0 — of  flaxseed  to 
I    quart — liter — of   water,   boiled    twenty   to    thirty   minutes    and 


436  DISEASES   OF  THE   STOMACH  AND  INTESTINES 

strained).  Temperature,  ioi°  to  103°  F.  This  should  be  rather 
thin  and  oily  in  order  to  flow  easily  from  a  fountain  syringe.  Dilute 
it  with  boiled  water  if  too  thick.  Normal  saline  solution  with  oil  of 
peppermint,  V([v  to  xv  (0.296-0.88  cc),  or  oil  of  cinnamon,  TTLv  to 
XV  (0.296-0.88),  to  I  pint  (500  cc).  lyisterin,  borolyptol,  glycothy- 
molin,  borax,  bicarbonate  of  soda ,  tannic  acid,  and  alum  have  been 
employed  at  a  strength  of  5]  (4.0)  to  i  quart  (liter). 


Fig.    195. — Enteroclysis    (double  current).     Self-irrigation   of   the  prostate  per 

rectum. 

Delafield  has  used  bichlorid  of  mercury  (1:10,000),  2  quarts 
(liters),  for  septic  membranous  colitis  complicating  typhoid  fever, 
with  a  recurrent  tube,  with  success.  Gum-arabic  solution  is  often 
of  service.     Special  solutions  are  described  appropriatelv. 

Normal  saHne  solution,  Sj  (4.0)  of  salt  to  i  pint  (500  cc.)  of  water, 
has  a  wide  field  of  usefulness. 

Enema ta  and  enteroclysis  are  of  value  in  d>senterv,  intestinal 
hemorrhage,^  intestinal  catarrh,  typhoid,  intestinal  colic,  tympanites, 

1  This  refers  to  hemorrhage  in  the  large  intestine,  where  an  extremely  hot  01 
cold  astringent  enema  is  of  service. 


MECHANICAL    PROCEDURES 


437 


intestinal  toxemias,  thirst,  constipation,  impaction,  intestinal  paresis, 
and  jaundice. 

They  are  extremely  useful  in  shock,  uremia,  sepsis,  renal  colic, 
and  in  inflammatory  conditions  of  the  genito-urinary  organs  of  both 
sexes. 

Proctoclysis. — In  conclusion,  I  wish  to 
refer  to  proctoclysis,  the  injection  of  normal 
saline  solution  into  the  rectum  by  the  drop 
method,  as  first  suggested  by  Dr.  John  B. 
Murphy  of  Chicago.  This  procedure  is  of 
special  value  in  sepsis,  and  is  of  use  as  an 
adjunct  to  other  treatment  in  postopera- 
tive shock,  intestinal  paresis,  and  uremia. 
In  my  experience  the  employment  of  con- 
tinuous (recurrent)  irrigation,  with  a  tem- 
perature of  the  saline  solution  at  120°  F., 
is  more  efficacious  in  the  latter  conditions, 
followed  by  proctoclysis  as  an  adjunct. 

One  of  the  difficulties  which  the  phys- 
ician must  endeavor  to  overcome  in  the 
administration  of  saline  solution  by  the 
rectum  or  by  infusion  is  the  maintenance 
of  a  constant  temperature  of  the  solution. 
Elbrecht's  apparatus  necessitates  a  special 
heating  chamber  in  addition  to  the  contain- 
ing reservoir,  with  the  employment  of  an 
electric  heater,  an  alcohol  lamp,  or  a  Bunsen 
burner.  The  method,  though  scientific, 
seems  complicated  and  is  quite  expensive. 

I  have  recently  employed  the  vacuum 
bottle^  with  a  specially  devised  attachment 
which  has  proved  efficacious  in  preserving 
the  saline  solution  at  a  constant  tempera- 
ture. The  device  is  readily  understood 
irom  the  illustration  (Fig.  196). 

Through  the  screw  cap  (B) ,  which  closes 
the  bottle,  passes  a  small  hard-rubber  con- 
ducting tube,  to  which  is  attached  the 
outflow  tube  (£).  Parallel  with  this  is 
the  filiform  tube  (C),  which  allows  the 
entrance  of  a  fine  column  of  air,  so  as  to 
render  the   flow   possible.     This  last  tube 

passes  through  the  solution  to  within  about  i  inch  from  the  bottom 
of  the  bottle.  As  the  instrument  is  employed  inverted,  it  would  cor- 
respond to  the  same  distance  from  the  top  of  the  bottle.     This  fili- 

1  New  York  Medical  Journal  and  Philadelphia  Medical  Journal  Incorporated, 
Aug.  14,  1909. 


Fig.     196. — Heat -retaining 
proctoclysis  bottle. 


438  DISEASES   OF  THE   STOMACH  AND  INTESTINES 

form  tube  is  of  hard  rubber  externally  where  exposed  to  the  air  as 
a  non-conductor  of  heat.  The  part  lying  within  the  bottle  is  pur- 
posely made  of  metal,  so  that  it  is  rapidly  heated  by  the  surround- 
ing solution  and  the  entering  air  is  thus,  in  turn,  heated  markedly. 

A  series  of  experiments  have  demonstrated  that  there  is  only  a 
loss  of  I  °  to  2  °  F.  in  the  temperature  of  the  solution  in  the  bottle 
during  the  administration  of  proctoclysis  (the  drop  method)  lasting 
half  an  hour,  a  negligible  amount.  The  screw  compression  valve  (D) 
is  applied  close  to  the  bottle  attachment,  so  as  to  avoid  as  much  as 
possible  the  solution  cooling  in  the  soft  outflow  tube.  This  outflow 
tube  (E)  is  joined  to  the  catheter  (G)  by  a  short  piece  of  glass  tubing 
(F),  for  the  purpose  of  observing  whether  the  flow  is  constant.  The 
catheter  for  rectal  injection  passes  through  a  self- retaining  rectal 
tip  (H),  and  the  former  can  be  inserted  to  any  length  desired.  The 
conducting  tube  (E)  is  especially  thick,  as  in  Elbrecht's  apparatus. 

An  asbestos  tube  surrounds  the  conducting  tube  from  its 
junction  at  the  bottle  to  the  catheter.  This  lessens  dissipation  of 
heat  and  obviates  the  use  of  hot  towels.  The  asbestos  wrapping  can 
be  occasionally  slipped  off  the  glass  connecting  joint,  so  as  to  observe 
the  flow.  The  vacuum  bottle  is  filled  in  the  usual  manner  and 
the  special  cap  with  attachment  screwed  on.  The  bottle  is  then 
inverted  and  suspended  in  a  cord  sling,  as  in  the  illustration.  A 
small  amount  of  fluid  will  escape  from  the  bottle  by  the  filiform  air 
tube  until  the  solution  reaches  the  level  of  the  tube,  which  now  lies 
near  the  top  of  the  bottle.  The  bottle  is  then  suspended  about  6 
inches  above  the  rectum  or  higher  if  desired,  and  the  flow'  tested  for 
the  proper  speed  before  inserting  the  rectal  tip  and  catheter. 

If  flatus  occur,  lower  the  reservoir  for  a  brief  period  to  below  the 
level  of  the  abdomen,  so  the  gas  may  escape  into  the  bottle.  At 
times,  however,  it  may  be  necessary  to  remove  the  tube  for  a  short 
period.  The  insertion  of  a  T-tube  between  the  reservoir  tube  and 
rectal  catheter  is  of  advantage.  A  short  piece  of  rubber  tubing  is 
attached  to  the  branch  and  immediately  clamped.  On  occurrence 
of  flatus,  the  lateral  clamp  is  removed  and  the  gas  allowed  to  escape. 
It  is  then  reclamped.  This  obviates  removal  of  the  tube.  As  al- 
ready stated,  there  is  practically  no  loss  of  heat  in  the  container,  all 
of  it  occurring  during  the  passage  of  the  drops  through  the  outflow, 
tube;  the  slower  the  speed,  the  greater  the  loss. 

At  the  start  the  speed  is  always  more  rapid  and,  though  gauged 
to  say  15  drops  per  minute,  may  in  the  course  of  two  minutes  drop 
to  5.  A  test  of  two  to  three  minutes  should,  therefore,  be  made 
before  inserting  the  catheter,  so  as  to  insure  a  constant  flow  at  the 
desired  rate.     The  following  table  will  be  found  of  service ;  with 


Temperature  of  water 

Length  of  tube 

Number  of  drops 

Temperature  in 

in  bottle. 

(inches). 

per  minute. 

rectum. 

160°  F. 

30 

20  or  less 

100°  F. 

150°  F. 

30 

40  to  50 

100°  F. 

138°  to  140°  F. 

30 

150  to  200 

105°  to  110°  F, 

MECHANICAL    PROCEDURES  439 

If  the  injection  is  given  at  a  greater  speed  than  200  drops  per 
minute,  the  solution  in  the  bottle  should  not  be  over  120°  F.,  as  there 
is  practically  no  loss  of  temperature.  This  method  by  enema  or 
recurrent  enteroclysis  would  be  of  great  value  in  shock.  It  could 
then  be  followed  by  proctoclysis  as  an  adjunct. 

Hypodermoclysis. — There  is  a  loss  of  10°  to  20°  F.  during  the 
injection,  depending  upon  the  size  of  the  hypodermic  needle. 

Infusion. — Dawbarn  advocates  a  temperature  of  115°  to  120°  F., 
preferably  the  latter;  time,  ten  minutes  to  the  liter  (quart). 

With  the  smaller  vacuum  bottle,  containing  about  i  quart  ( liter), 
a  glass  V  tube  can  be  inserted  between  the  conducting  tube  and  the 
rubber  tube  for  attachment  to  the  infusion  canula.  By  this  means 
it  is  possible  to  tell  when  the  bottle  is  empty  and  thus  prevent  the 
entrance  of  air.  A  clamp  can  be  applied  close  to  the  V  tube  on  the 
canula  side  and  the  bottle  refilled,  the  v  tube  being  refilled  before 
the  conducting  tube  is  reattached,  and  the  latter  being  done  while 
the  solution  is  flowing. 

A  larger  bottle  can  be  secured  for  infusion,  but  the  smaller  one 
can  be  employed  with  these  precautions. 


Fig.  197. — Tiirck's  double-current  needle  douche  for  the  sigmoid. 

The  temperature  of  the  saline  solution  does  not  practically 
change  during  the  infusion  and  should  be  at  115°  to  120°  F.  in  the 
reservoir. 

Needle  Douche  ;  Nebulizer ;  Colonic  Massage  Bags  ;  Gyro- 
mele. — These  instruments^  have  been  devised  by  F.  B.  Tiirck. 
The  colon  needle  douche  (Fig.  197)  I  believe  of  some  value  for  local 
treatment  by  the  alternate  hot  and  cold  spray  in  the  atonic  type  of 
constipation. 

.  The  nebuHzer  (Fig.  198)  is  recommended  by  its  inventor  for 
spraying  oils  of  cloves  or  cinnamon  into  the  colon  for  their  antiseptic, 
analgesic,  and  vasomotor  effect. 

He  recommends  distensible  bags  for  massage  of  the  atonic  sig- 
moid and  rectum,  which  I  hardly  advocate. 

The  gyromele,  already  described,  Tiirck  recommends  in  the  rec- 
tum and  sigmoid  for  cleansing  the  mucosa  and  producing  vibratory 
movements.  I  question  the  possibility  of  its  entering  into  the  sig- 
moid flexure  except  very  rarely. 

Massage,  Gymnastics,  and  Exercise. — The  general  methods 
of  massage  have  been  described.  The  course  of  the  colon  should 
be  followed.     The  cannon-ball  and  vibratory  massage  are  of  service. 

'  Tournal  American  Medical  Association,  May,  1895. 


440 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


The  portable  Vedee  vibrator  is  a  useful  instrument  for  the  general 
practitioner.  It  is  illustrated  in  Part  II  of  this  volume.  Gym- 
nastic exercises  and  out-of-door  sports  are  valuable  for  strengthening 
the  abdominal  and  intestinal  musculature,  especially  in  intestinal 
atony  with  constipation.  Rowing  with  a  sliding  seat,  golf,  horse- 
back-riding, bicycling,  and  walking  are  useful. 

Mechanical  Support. — Adhesive  strapping  (Rose's  belt),  abdom- 
inal supporters,  etc.,  are  indicated  in  enteroptosis,  in  atonic  condi- 
tions of  the  intestines  or  of  the  musculature  of  the  abdominal  wall, 
in  hernial  protrusions,  etc. 

Hydrotherapy. — The  Priessnitz  compress,  poultices,  and  the 
application  of  heat  or  cold  locally  are  useful. 


Fig.  198. — Tiirck's  nebulizer. 


Sitz-baths  and  abdominal  douches  are  employed  as  already 
described. 

Electricity. — Galvanic,  faradic,  and  static  electricity  may  be 
employed  percutaneously.  The  faradic,  chiefly  in  atonic  conditions ; 
the  galvanic,  in  painful  neurotic  affections.  Static  electricity  can 
be  used  for  both  purposes. 

About  ten  to  fifteen  minutes  is  the  average  period  of  treatment. 
When  externally  applied  the  current  should  follow  the  course  of  the 
colon  and  then  be  given  over  the  small  intestine.  Electric  vibration 
may  be  used. 

Violet  rays,  the  high-frequency  current,  etc.,  have  been  advo- 
cated for  various  conditions,  but  further  investigation,  I  believe,  is 
necessary  before  they  can  be  recommended.  The  application  of 
heat  and  Hght  (electric -light  bath)  to  the  abdomen  in  painful  con- 
ditions due  to  a  gouty  or  rheumatic  tendency,  or  in  enteroptosis  or 


MECHANICAL    PROCEDURES  44 1 

mucous  colic  its  application  to  the  sensitive  areas  may  prove  of 
service. 

Intrarectal  Electricity. — Boudet's  electrode  presents  the  disadvan- 
tage that  sometimes  frequent  evacuations  necessitate  withdrawal 
of  the  electrode. 

The  author's  instrument  (Fig.  189)  consists  of  a  recurrent  irri- 
gator, external  tube  hard  rubber,  internal  tube  metal,  with  an 
attachment  for  a  battery  pole;  a  sponge  attached  to  the  other  pole 
is  placed  over  the  abdomen.  Continuous  enteroclysis  is  given  with 
hot  normal  saline  solution,  the  water  carrying  the  current. 

The  treatment  should  be  given  for  five  to  thirty  minutes,  depending 
on  the  indications.  It  is  excellent  for  simple  atonic  constipation 
and  for  intestinal  paresis.  The  faradic  current  is  preferable,  as  strong 
as  the  patient  can  bear.  The  galvanic  may  be  employed,  with  nega- 
tive pole  in  the  rectum,  with  a  current  of  10  to  15  milliamperes. 


CHAPTER  XXI 

DIET;  INTESTINAL  DYSPEPSIA;  INDICANURIA;  SAC- 
CHAROBUTYRIC  PUTREFACTION ;  BOTULISM ; 
HYDROGEN  SULPHID  AUTO-INTOXICATION;  EN- 
TEROGENIC  CYANOSIS;  METEORISM;  ENTER AL- 
GIA;  VISCERAL  ARTERIOSCLEROSIS;  ANOMALIES; 
INTESTINAL  SAND 

DIET 

The;  general  principles  of  diet  were  described  in  Diseases  of  the 
Stomach.  I  will  briefly  mention  a  few  general  rules  which  should 
be  applied. 

Acute  intestinal  disorders  must  be  managed  on  the  principle  of 
rest.  Ivight  food  (chiefly  liquid)  should  be  given,  such  as  broths, 
barley-water,  gruels,  kumyss,  matzoon,  bacillac,  lactone-buttermilk, 
and  in  some  cases  milk,  but  diluted  with  barley-water  or  Hme- water. 
It  has  been  demonstrated  that  in  the  acute  intestinal  catarrh  of  infants 
and  children,  undiluted  (or  at  times  even  diluted)  milk  will  frequently 
pass  undigested  and  intensify  the  inflammatory  process,  so  that  reli- 
ance is  placed  for  a  time  on  barley-water  and  similar  preparations. 

Seibert  has  demonstrated  conclusively  that  milk  is  not  the  ideal 
food  for  typhoid  fever. 

In  chronic  intestinal  disease,  for  a  brief  period,  rest  may  be  given 
to  the  intestines  by  means  of  a  fluid  diet,  but  feeding  should  soon  be 
increased,  the  general  nutrition  improved,  and  the  intestional  tract 
gradually  accustomed  to  a  regular  diet,  if  such  be  possible.  Milk, 
cream,  raw  eggs,  carbohydrates,  and  fats  are  of  value  to  improve 
nutrition. 

In  these  chronic  cases  especially,  and  also  in  intestinal  dyspepsia, 
all  or  some  special  digestive  function  may  be  disturbed,  such  as  for 
proteids,  fats,  or  carbohydrates.  The  presence  of  indicanuria,  the 
test  diet  with  stool  examination,  the  fermentation  test,  together  with 
the  clinical  symptoms,  will  determine  the  type  of  disturbance  of  the 
intestinal  digestive  function.      The  findings  would  modify  the  diet. 

Dietetic  measures  are  of  special  value  in  reference  to  disturbances 
accompanied  by  constipation  or  diarrhea. 

I.  Laxative  foods  are  articles  which  increase  intestinal  peristalsis. 
Among  such  are  fruit  juices  and  raw  and  cooked  fruits,  such  as  apples, 
pears,  plums,  peaches,  strawberries,  gooseberries,  dates,  and  figs. 
Salads,  garden  vegetables,  due  to  water  contained  and  indigestible 
residue,  such  as  melons,  cucumbers,  spinach,  tomatoes,  pumpkins, 
and  cabbage;  cider,  bonny-clabber,  kumyss,  matzoon,  and  bacillac, 

442 


DIET  443 

through  formation  of  acid  products  and  gas,  increase  peristalsis. 
Some  of  the  fruits  and  vegetables  mentioned  have  a  similar  effect. 
Brown  bread  and  oatmeal  tend  to  move  the  bowels,  also  water  or 
carbonated  waters.  Sugar  has  a  laxative  effect.  Considerable  fat, 
in  the  form  of  cream,  butter,  or  olive  oil,  aids  bowel  action. 

2.  Constipating  Foods. — Among  such  are  substances  containing 
astringent  agents,  especially  tannic  acid,  such  as  tea,  dried  bilberries, 
French  red  wines,  cocoa,  the  acorn  preparations,  such  as  acorn 
coffee,  acorn  cocoa;  mucilaginous  foods,  such  as  sago,  tapioca,  rice, 
and  barley;  also  foods  which  leave  little  residue  and  exert  no  irrita- 
tion, such  as  albumen- water  (white  of  egg  dissolved  in  water),  scraped 
raw  beef,  mutton  broth,  etc. 

Pathologically,  excess  of  carbohydrates  may  be  a  cause  of  diarrhea, 
as  may  excess  of  proteids. 

Milk  is  constipating  in  one  person,  laxative  in  another,  and  has 
no  special  effect  on  others.     Boiled  milk  is  usually  constipating. 

Dietetics  have  changed  markedly  during  the  last  few  years. 
In  chronic  colitis  with  diarrhea  the  chief  diet  was  formerly  scraped 
meat.  Modern  methods  allow  a  much  greater  variety,  and  the  em- 
ployment of  mashed  potatoes  and  boiled  rice  lessen  peristalsis  and 
are  often  of  considerable  value. 

Certain  foods,  when  taken  under  ordinary  conditions,  have  no 
marked  influence  in  increasing  peristalsis ;  among  these  are  meats, 
fish,  meat  powders,  artificial  foods,  such  as  peptone,  nutrose,  soma- 
tose,  sanatogen,  plain  or  flavored;  eggs,  well-baked  bread  (wheat), 
crackers,  zwieback,  and  butter  or  fat  in  small  amount. 

Marked  seasoning  of  foods  increases  peristalsis.  The  finer  the 
particles  of  food,  the  less  the  irritation ;  the  coarser  they  are,  the 
greater  stimulation  the}^  produce  on  the  intestines. 

Gelatin. — I  have  referred  to  the  value  of  gelatin  in  ulcer  of  the 
stomach  and  in  hyperchlorhydria.  Gelatin  does  not  build  up  new 
tissue,  no  matter  how  much  is  ingested,  though  it  may  diminish 
tissue  waste  (Voit).^     It  cannot  be  reconverted  into  a  proteid. 

Kirchmann^  shows  that  gelatin  spares  proteid  in  metahoUsw,. 
-  The  ingestion  of  7.5  per  cent,  of  the  total  heat'*  requirement  of 
the  organism  in  the  form  of  gelatin  spares  23  per  cent,  of  the  body's 
proteid,  while  60  per  cent,  gelatin  reduces  it  35  per  cent.  The  small 
amount  of  gelatin  has  nearly  as  much  effect  as  larger  quantities. 
Its  value  in  typhoid  is,  therefore,  evident  to  lessen  nitrogen  excretion. 

Kaufmann*  shows  that  when  the  lacking  tyrosin,  cystein,  and 
tryptophan  are  mixed  with  gelatin  in  the  proportion  in  which  they 
occur  in  true  proteid,  and  are  given  to  a  dog  or  man,  nitrogen  equilib- 
rium may  be  established. 

1  Hermann's  Handbuch  Stoffwechsel,  1881,  p.  396. 
^  Zeitschrift  fiir  Biologie,  1900,  Bd.  xl,  p.  54. 

3  One  gm.  of  gelatin  furnishes  4.1  calories.     About    50  gm.  of  gelatin  repre- 
sents this  requirement  in  a  person  weighing  154  pounds. 
*  Pfliiger's  Archiv.,  1905,  Bd.  clx,  jx  440. 


444  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

Gelatin  does  not  yield  indol,  and  can  be  employed  in  the  form  of 
jellies  as  a  nitrogenous  substance  to  replace  proteids  in  cases  of 
indicanuria  (Herter).^ 

In  severe  inflammation  of  the  intestines  artificial  feeding  may  be 
necessary,  by  rectum  or  subcutaneously. 

Rectal  alimentation  has  been  described  under  Diet,  in  Part  II. 

Sterile  olive  oil,  oj  to  ij  (30.0-60.0),  may  be  injected  subcu- 
taneously two  or  three  times  a  day  between  the  crest  of  the  ileum  and 
lower  border  of  the  ribs  (preferably).  Sterile  almond  oil  in  doses 
of  oj  to  ij  (4.0-8.0)  may  be  substituted.  I  do  not  advocate,  how- 
ever, the  subcutaneous  method. 

Normal  saline  solution,  Oj  (500  cc.)  to  i  quart  (liter),  may  be 
slowly  injected  in  the  same  region  in  case  of  collapse  or  hemorrhage. 

INTESTINAL  DYSPEPSIA 

With  intestinal  catarrh  or  biliary  or  pancreatic  obstruction  there 
is  perversion  of  intestinal  digestion.  These  conditions  will  not  be 
considered  here. 

Digestive  processes  in  the  intestine  may  become  abnormal  when 
the  intestinal  contents  are  no  longer  normal.  This  may  occur  even 
with  intact  mucosa  and  with  sufficient  bile  and  pancreatic  juice. 
Indigestible  food,  or  excess  in  some  special  types  of  food,  may  lead  to 
fermentative  or  putrefactive  processes  in  which  bacteria  take  part, 
and  may  produce  dyspeptic  symptoms. 

Indicanuria  or  saccharobutyric  putrefaction  occur  from  these 
conditions. 

There  may  be  functional  disturbances  of  pancreatic  digestion 
for  the  proteids,  carbohydrates,  and  fats,  or  any  one  or  two  of  these 
functions  may  be  disturbed. 

Riegel  describes  cases  with  marked  fermentation  of  the  carbo- 
hydrates. There  is  a  jejunal  diarrhea  of  gelatinous  semifluid  char- 
acter, often  quite  green,  with  bile-pigment  reaction  and  acidity. 
There  is  mucus  in  these  movements,  but  no  formed  elements,  such  as 
epithelial  and  round  cells,  which  occur  in  catarrhal  conditions. 
Catarrh  may  ultimately  result. 

Herter^  shows  that  there  is  an  intestinal  indigestion  in  children 
of  marantic  type,  in  which  there  is  intolerance  to  carbohydrates, 
and  light  colored  and  gray  or  fatty  stools  occur.  Indican  and  phenol 
are  found  in  large  amount  in  the  urine.  A  great  number  of  Gram- 
positive  bacilli  of  the  Bacillus  bifidus  type  occur  in  these  cases. 

Schmidt  and  Strassburger  describe  "intestinal  fermentation" 
as  dyspepsia  in  which  the  stools  are  light  yellow,  foamy,  with  the 
odor  of  butvric  acid.  Fatigue,  discomfort,  loose  stools,  or  even  diar- 
rhea may  occur.  Abdominal  pains,  distention,  and  some  tenderness 
may  be  present.     These  cases  correspond  to  saccharobutyric  putre- 

1  Bacterial  Infections  of  the  Digestive  Tract,  p.  267.  ^  ibid.,  p.  285. 


INDICANURIA  445 

faction  (Herter).^  Dyspeptic  symptoms  may  be  due  to  the  decompo- 
sition of  proteids.^  Various  symptoms,  as  stated,  may  be  present  with 
intestinal  dyspepsia,  such  as  distention,  pain,  borborygmi,  passage 
of  flatus,  feeling  of  discomfort  in  the  abdomen.  Diarrhea  or  irreg- 
ularity of  the  bowels  is  present;  loss  of  appetite,  eructations,  nausea, 
and  even  vomiting  may  occur.  The  best  method  of  determining  the 
intestinal  functions  is  by  the  Schmidt  test  diet,  with  examination  of 
the  stool. 

Treatment. — That  variety  of  food  must  be  limited  for  which  the 
particular  disturbance  exists.  Liquid  or  semiHquid  diet  may  be 
necessary.  Indicanuria  and  saccharohutyric  putrefaction  must  be 
appropriately  treated. 

Lactic  acid  has  been  recommended  in  the  form  of  ferm.ented 
milks,  such  as  kumyss,  matzoon,  bacillac,  kefir,  or  lactone-butter- 
milk;  chicken,  jellies,  gruels,  etc.,  can  be  given  later. 

Calomel,  gr.  ^V  (0.0016)  four  times  a  day,  is  suggested  by  Van 
Valzah^  for  fermentation;  or  resorcin,  gr.  5  (0.3)  t.  i.  d.,  is  excellent. 

Taka-diastase,  gr.  5  (0.3)  t.  i.  d.,  is  valuable  in  am3daceous 
dyspepsia*;  or  pancreon,  gr.  5  (0.3)  t.  i.  d.,  in  disturbances  of  fat  and 
proteid  digestion,^  and  pancreatin,  same  dosage. 

In  conclusion,  I  would  advise  that  in  the  milder  cases  the  special 
food  stuff  which  causes  dyspepsia  should  be  limited  in  quantity,  but 
not  entirely  cut  off.  Eggs,  soft  boiled  or  raw,  vegetables  in  mashed 
forms,  bread  or  crackers,  stale  and  well  broken  up,  and  sanatogen 
are  of  service ;  butter  or  cream  according  to  indication.  Later  the 
diet  is  increased. 

INDICANURIA 

Indicanuria  designates  the  presence  of  indican  in  the  urine,  as 
demonstrated  by  reactions  with  the  formation  of  indigo,  on  using 
Jaffe's,  Obermeyer's,  or  similar  tests. 

Indol  is  absorbed  from  the  intestines  and  forms  in  the  liver 
indoxyl  potassium  sulphate  or  indican,  an  ethereal  sulphate  which 
is  eliminated  in  the  urine. 

There  are  various  causes  of  indicanuria:  excessive  proteid  diet, 
catarrh  of  the  small  intestine,  causing  alterations  in  the  mucosa  and 
increased  intestinal  putrefaction,  typhoid,  cholera,  etc.,  constipation, 
alimentary  putrefaction,  partial  or  complete  obstruction  of  the  com- 
mon bile-duct,  decrease  of  normal  digestive  fluids,  intestinal  obstruc- 
tion, and  peritonitis.  Certain  drugs,  such  as  salol,  salophen,  and 
creosote,  give  reactions  which  must  not  be  mistaken  for  it,  while 
urotropin  causes  its  disappearance. 

1  Bacterial  Infections  of  the  Digestive  Tract,  ]ip.  294,  300.     2  ibid.,  pp.  280,  306. 

3  Medical  News,  Jan.  17,  1903. 

*Cellasin,  gr.  5  to  10  (0.3-0.6),  given  t.  i.  d.  an  hour  after  meals  in  combina- 
tion with  bicarbonate  of  soda,  gr.  10  (0.6),  has  of  late  proved  valuable  in  amyla- 
ceous and  fatty  dyspepsia. 

5  True  Intestinal  Dyspepsia  (Einhorn),  American  Jour,  of  Med.  Sciences,  No- 
vember, 1907;  also  Med.  Record,  September  4,  1909. 


446  DISEASES    OE   THE    STOMACH   AND   INTESTINES 

Intestinal  indicanuria  is  an  evidence  of  intestinal  putrefaction. 
Excessive  quantity  of  proteid,  especially  of  meat,  may  be  a  cause. 
Any  condition  favoring  stagnation  in  the  intestines  helps  produce  this 
condition.      Imperfect  action  of  a  cathartic  can  produce  indicanuria. 

In  children  little  indican  appears.  IMany  adults  show  indican 
and  suffer  from  no  symptoms,  but  this  is  true  of  constipation. 
Finally,  persons  with  indicanuria  show  clinical  evidences  of  intestinal 
disorder  and  sometimes  symptoms  of  auto-intoxication,  frequently 
affecting  the  nervous  system.  Neurasthenic  and  even  melancholic 
symptoms  may  be  dependent  on  this  form  of  auto-intoxication. '^ 
Intestinal  putrefaction^  may  directly  affect  the  liver  and  kidneys.  "I 
have  a  patient  with  marked  indicanuria  with  bile  in  the  urine, 
albumin  casts,  cylindroids,  and  diminished  urea.  Treatment  of  the 
intestinal  putrefaction  cleared  up  this  condition. 

This  corroborates  the  view  of  W.  H.  Porter^  that  excessive 
intestinal  putrefaction  may  cause  disturbance  of  the  hepatic  cells. 
There  was  no  jaundice  in  this  patient.  The  colon  bacilli,  through 
their  activity  in  the  decomposition  of  proteids,  are  chiefly  responsible 
for  the  production  of  indol.  The  Bacillus  aerogenes  capsulatus 
and  the  Bacillus  putrificus,  when  present,  favor  the  putrefactive 
action  of  the  colon  bacilli  on  the  proteids.* 

The  following  test  is  reliable :  Place  in  a  test-tube  equal  quantities 
(lo  cc.  of  each)  of  urine  and  chemically  pure  concentrated  hydro- 
chloric acid.  To  this  mixture  add  3  drops  of  i  per  cent,  solution  of 
potassium  permanganate.  Then  add  a  small  portion  of  chloroform, 
I  or  2  more  drops  of  the  permanganate  solution,  and  a  few  drops 
more  of  chloroform,  or  a  total  of  75  drops  (5  cc.)  of  chloroform,  and 
shake  vigorously  for  a  few  seconds. 

Indigo-blue  is  deposited  in  presence  of  this  indicator.  Bile 
should  be  tested  for  even  if  there  are  no  evidences  of  jaundice. 
W.  H.  Porter's  scale  (Plate  I)  is  a  basis  of  comparison  in  the  ab- 
sence of  bile  test.     The  color  scale  of  complex  indicanuria  is  omitted. 

Rosenbach's  test,  which  consists  in  boiling  the  urine  with  nitric 
acid,  gives  a  Burgundy  red  if  putrefaction  is  present.  This  may  occur 
when  no  indican  is  found.  It  is  due  to  substances  of  a  like  class. 
Taylor^  recently  reports  transient  heart  block  due  to  indicanuria. 

Treatment. — Diet. — Matzoon,  kumyss,  lactone-buttermilk,  bacil- 
lac ;  later,  stale  crackers  with  butter,  boiled  rice,  and  jellies  (gelatin) 
are  to  be  added.  Herter  shows  that  clinically  the  carbohydrates  have 
an  influence,  and  the  substitution  of  a  quickly  digested  carbohydrate, 
like  rice  which  has  been  well  cooked  and  forced  through  a  colander, 

1  Headache,  migraine,  myasthenia,  epileptiform  seizures,  early  fatigue,  cycli- 
cal vomiting,  or  progressive  muscular  atrophy  may  also  be  dependent  on  this 
condition  (Herter). 

2  This  condition,  I  believe,  further  influences  the  production  of  arteriosclerosis. 

3  The  Post-graduate,  Oct.,  1902. 

*  Herter,  Bacterial  Infections  of  the  Digestive  Tract. 
5  Jour.  Amer.  Med.  Assoc,  April  18,  1908. 


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SACCHAROBUTYRIC    TYPE    OF    INTESTINAL   PUTREFACTION         447 

for  large  quantities  of  bread  or  sugar,  will  lessen  the  excretion  of 
indican.     Taka-diastase  or  cellasin  can  also  be  given. 

Medication. — Blue  mass,  gr.  5  (0.3);  calomel,  gr.  5  (0.3),  once 
a  week,  and  a  saline  (cathartic  for  a  short  period)  daily. 

Urotropin,  gr.  5  (0.3),  with  benzoate  of  soda,  gr.  10  (0.6)  t.  i.  d., 
has  cleared  up  many  cases,  albumin  casts,  bile,  and  indican  disap- 
pearing within  a  short  time.  This  shows  the  improvement  was  not 
due  to  the  mere  interference  with  indican  reaction.  Lacto-bacillin 
tablets  are  useful.     Those  advocated  by  Metchnikoff  are  best. 

Aspirin,  salicylate  of  soda,  and  salol,  gr.  5  to  10  (0.3-0.6),  are 
of  service,  as  is  also  chologestin,  oij  to  iij  (8.0-12.0),  t.  i.  d. 

Enteroclysis  is  valuable,  especially  the  injection  of  i  pint  to  i 
quart  (500-1000  cc.)  of  a  i :  1000  acetozone  solution,  with  the  patient 
in  the  knee-chest  posture.  This  should  be  retained  for  a  short  time. 
This  procedure  can  be  carried  out  every  day  or  few  days.  Gastric 
disturbances  should  be  investigated  and  corrected. 

George  A.  Tuttle  has  shown  that  potassium  iodid,  especially  in 
cases  with  arteriosclerosis,  will  lessen  indican.  Basham's  tincture 
has  been  of  benefit  in  some.  Some  have  advocated  acetozone  solu- 
tion, (i :  1000),  500  cc.  (i  pint),  in  divided  doses  daily  by  mouth. 

SACCHAROBUTYRIC  TYPE  OF  INTESTINAL  PUTREFACTION 

This  type  of  decomposition  is  produced  chiefly  by  the  Bacillus 
aerogenes  capsulatus,^  Gram-positive.  Bacillus  putrificus  or  Gram- 
positive  diplococci  may  at  times  be  associated. 

The  Bacillus  aerogenes  under  anaerobic  conditions  can  attack 
carbohydrates  and  proteids.  Butyric  acid  is  often  formed  in  con- 
siderable amount,  and  often  propionic,  caproic,  or  valeric  acids. 
The  odor  of  the  movements  is  often  intense  and  characteristic  of 
butyric  or  caproic.  acid.  Excessive  gas  is  liberated.  The  seat  of 
this  process  is  chiefly  in  the  large  intestine  and  lower  ileum. 

When  proteids  are  attacked  there  is  less  gas  liberated.  With 
excessive  gas  production  the  feces  have  a  low  specific  gravity  and 
float  on  water.  There  are  small  bubbles  in  the  contents  and  the  feces 
are  a  light  color.  Patients  who  suffer  from  this  condition  do  not 
tolerate  well  either  carbohydrates  or  acids,  flatulence  and  diarrhea 
occurring  after  use  of  cereals,  starchy  food,  and  especially  sugar. 
The  mucous  membranes  of  the  digestive  tract  are  easily  irritated, 
and  there  may  be  epithelial  desquamation  in  the  mouth.  In  the 
simple  cases  indol  is  generally  absent. 

Combined  Saccharobutyric  and  Indolic  Type. — The  Bacillus 
aerogenes  capsulatus  is  also  able  to  break  down  proteids  into  a  suit- 
able form  for  the  use  of  other  putrefactive  bacteria,  among  which  are 
the  indol-forming  organisms. 

This  last  form,  associated  with  the  excessive  production  of  indol, 
is  the  most  severe  type,  and  these  cases  are  subject  to  auto-intoxica- 
1  Herter,  Bacterial  Infections  of  the  Digestive  Tract. 


448 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


tion,  depressive  mental  conditions,  and  diminution  in  muscular 
power  (muscle  fatigue),  according  to  Herter. 

In  the  severe  types  the  anaerobic  organisms,  especially  the 
Bacillus  aerogenes  capsulatus,  produce  hemolytic  substances  which 
are  believed  to  have  a  bearing  on  the  production  of  pernicious  anemia. 

The  results  of  intestinal  irrigation  in  such  cases  have  been  favor- 
ably reported  by  Hollis^  and  Ditman,"  as  in  Fig.  199,  with  marked 
improvement  in  the  hemoglobin  and  red  cells. 


- 

Nov. 

DeoenalDer 

January 

February 

in  arch 

Hemo- 
globin 

Red  Blood 

Cells 

33  SO 

3      0        15     SQ 

S    10     IS     se 

X       7        13       SI 

1        7        13 

Indican 

Very  StfOrg 

Stiong 

Modofale 

100% 

5,000,000 
4,500,000 
4,000,000 
3,500,000 
3,000.000 

90% 

/ 

/^ 

s 

80% 

J 

/ 

70% 

/ 

/ 

/■» 

•^ 

60% 

/ 

/ 

/ 

60% 

\ 

<^ 

1 

/ 

/ 

V 

40% 

2,000,000 

1,500,000 

1,000,000 

500,000 

0 

\ 

y 

\ 

/ 

/ 

/ 

30% 

Y 

AJ 

1 

< 
\ 

\ 

N 

/ 

/ 

20% 

/ 

\ 

\/ 

V 

< 

\ 

\ 

^S^ 

y 

10% 

\ 

0% 

1 

_^ 

1 

Fig.  199. — Chart  of  pernicious  anemia  demonstrating  value  of  enteroclysis. 

Arthritis  deformans^  has  recently  been  imputed  to  putrefactive 
changes  in  the  intestinal  canal.  At  the  Red  Cross  Hospital  excellent 
results  were  secured  by  the  author  by  enteroclysis  and  fermented 
milks,  no  medication;  the  swelling  in  the  joints  rapidly  subsiding. 

Treatment. — Careful  mastication  of  the  food,  cleanliness  of  the 
mouth,  and  correction  of  gastric  disturbances  are  necessary.  Sugars 
should  be  omitted,  starchy  food  cut  down,  and  meat  diminished  or 
eliminated  if  the  mixed  type  with  indican  is  present. 

Taka-diastase,  gr.  5  (0.03)  t.  i.  d.,  aids  starch  digestion.     Pan- 

1  Herter,  Bacterial  Infections  of  the  Digestive  Tract. 

2  Medical  Record,  Feb.  2,  1907. 

3  A  Preliminary  Report  on  the  Relation  of  Albuminous  Putrefaction  in  the 
Intestines  to  Arthritis  Deformans  by  Andrews  and  Hoke,  American  Journal  of 
Orthopedic  Surgery,  July,  1907. 


HYDROGEN    SULPHID   AUTO-INTOXICATION  449 

creatin  preparations  may  be  tried.     The  fermented  milks  are  of  spe- 
cial value.     Lactobacillin  tablets  are  useful. 

Enteroclysis,  or  high  enema,  with  saline  solution,  acetozone 
(i:  1000)  or  hydrogen  peroxid  (1:1000)  are  of  service.  The  latter 
are  of  special  value. 

Ichthoform,  formidin,  ichthalbin,  aspirin,  salol,  salicylate  of 
soda,  gr.  5  (0.3)  t.  i.  d.,  are  useful;^  or  urotropin,  gr.  5  (0.3),  with 
benzoate  of  soda,  gr.  10  (0.6),  t.  i.  d.  This  last  combination,  with 
the  addition  of  the  high  enema  of  acetozone  i  quart  (liter),  strength 
1 :  1000,  I  have  found  of  great  value.  Surgery-  may  be  indicated  in 
extreme  cases. 

BOTULISM 

This  is  a  variety  of  meat-poisoning  due  to  the  Bacillus  botulinus, 
isolated  by  Van  Ermengen  from  raw  ham.  The  symptoms  resembled 
those  of  so-called  sausage-poisoning.  This  same  type  of  poisoning 
has  occurred  from  eating  beans  that  were  imperfectly  canned.  These 
were  probably  infected  through  the  manure  of  pigs.  Meat  may  be 
extensively  infected  with  the  Bacillus  botuHnus,  and  contain  a  large 
quantity  of  the  toxins,  without  showing  the  signs  of  decomposition. 
The  filtered  toxins  can  produce  the  effects. 

Incubation. — The  symptoms  seldom  appear  before  twelve  to 
twenty -four  hours  after  ingestion  of  the  infected  meat.  They  are : 
First,  disturbances  of  the  external  muscles  of  the  eyeball,  such  as 
ptosis,  abducens  paralysis,  disturbances  of  associated  movements 
with  nystagmus;  second,  disturbances  of  the  internal  muscles  of  the 
eyes,  such  as  enlargement  and  rigidity  of  the  pupils;  third,  there  are 
swelling  or  paralysis  of  the  tongue,  pharyngeal  and  laryngeal  paral- 
yses, and  disturbances  of  the  heart  and  respiration;  fourth,  there 
may  be  weakness  or  paralysis  of  motion.  Changes  in  sensibility 
and  consciousness  usually  do  not  accompany  these  disturbances. 
Fever  has  frequently  been  absent  and  there  has  even  been  absence 
of  disturbances  of  the  stomach  and  intestines.  This  condition  is 
not  so  rare  abroad  and  occurs  in  this  country. 

Treatment. — Evacuation  of  the  gastro-intestinal  tract.  Treat- 
ment of  symptoms.  Herter  recommends  Kempner's  antitoxin  when 
procurable. 

HYDROGEN  SULPHID  AUTO-INTOXICATION 

In  health  the  formation  of  hydrogen  sulphid  seems  probably 
limited  to  the  large  intestine  and  a  small  adjacent  portion  of  the 
small  intestine.     Under  pathologic  conditions  it  is  formed  in  other 

1  Permanganate  of  potash  up  to  gr,  i  fo.o6)  t.  i.  d.  may  be  of  service.  Herter 
suggests  the  possible  value  of  dioxid  of  manganese. 

2  If  dilatation  of  the  stomach,  not  responding  to  medical  treatment,  is  the 
cause,  then  gastro-enterostomy  is  indicated.  With  failure  of  medical  treatrnent 
and  progressive  anemia  and  mental  disturbances,  Herter  suggests  appendicos- 
tomy  followed  by  enteroclysis.  I  am  opposed  to  shortening  or  short  circuiting 
the  large  intestine  for  this  condition.  In  extreme  cases  Gant's  cecostomy,  with 
irrigation  of  colon  and  ileum,  might  be  of  service. 

20 


450  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

parts  of  the  digestive  tract.  In  chronic  ectasia  hydrogen  sulphid 
is  at  times  liberated  when  putrefactive  changes  take  place.  Herter 
believes  the  eructation  generally  occurs  from  this  viscus,  so  that  no 
symptoms  result.  He  holds  that  the  stagnating  stomach  contents 
probably  go  on  to  the  formation  of  cystin,  and  that  the  Bacillus 
lactis  aerogenes,  Bacillus  coU,  and  other  bacteria  produce  hydrogen 
sulphid  therefrom.  Senator^  reports  a  case  of  auto-intoxication  from 
hydrogen  sulphid  (hydrothionemia).  After  an  error  in  diet  the  patient 
became  ill  with  gastro-enteric  catarrh.  On  the  third  day  vomiting 
accompanied  with  the  odor  of  hydrogen  sulphid  occurred.  The 
patient  became  dizzy  and  went  into  collapse,  without  loss  of  con- 
sciousness. The  eructation  of  gas  continued,  and  the  first  urine 
gave  the  reaction  of  hydrogen  sulphid.     The  case  recovered. 

Betz^  and  Stefanio  and  Emminghaus  ^  describe  cases.  Head- 
ache, dizziness,  delirium,  mental  depression,  drowsiness,  stupor,  and 
collapse  were  prominent  symptoms. 

Treatment. — Catarrh  of  the  gastro-intestinal  tract,  ectasia,  and  in- 
testinal putrefaction  must  receive  appropriate  treatment  as  required. 

ENTEROGENIC  CYANOSIS 

This  peculiar  type  of  auto -intoxication  was  first  described  by 
Stokvis.*  The  patient,  aged  fifty-eight,  suffered  from  severe  enteritis 
with  pronounced  cyanosis  of  the  skin  and  visible  mucous  membranes, 
together  with  a  swelling  of  the  terminal  phalanges.  Spectroscopic 
examination  of  the  skin  and  mucous  membranes  showed  a  band 
corresponding  to  the  absorption  spectrum  of  methemoglobin.  It 
was  believed  that  poison  substances  were  formed  in  the  intestine 
which  transformed  part  of  the  hemoglobin  into  methemoglobin. 
Talma^  reported  3  cases.  Van  der  Bergh®  reported  2  cases,  one  of 
which  was  evidently  due  to  sulphemoglobin  (from  hydrogen  sul- 
phid) in  the  blood,  and  in  the  other  the  blood  contained  nitrites. 

Van  der  Bergh  also  reports  a  case  in  a  child  nine  years  of  age,  who 
suffered  from  marked  digestive  disturbances  with  diarrhea.  Anuria 
was  marked.  Child  was  very  cyanotic  and  the  ends  of  the  fingers 
were  clubbed;  abdominal  distention  marked.  Urine  contained  no 
albumin,  no  sugar,  but  a  little  indol.     No  cardiac  affection  present. 

Several  cases  of  sulphemoglobinemia  have  been  associated  with 
obstinate  constipation,  the  relief  of  which  has  been  follov/ed  by 
improvement. 

Treatment. — This  should  be  directed  to  the  intestinal  tract. 
Proteids  should  be  reduced ;  sour  milks  given ;  enteroclysis  and  the 
general  treatment  of  intestinal  putrefaction. 

1  Berlin,  klin.  Wochenschr.,  v,  p.  254,  1868.       2  Memorabilien,  Ix,  p.  145,  1864. 
^Berlin,  klin.  Wochenschr.,  Ix,  pp.  477,  491,  1872. 

*  Festsch.  f.  V.  Leyden,  1,  p.  597,  1902. 

'  Tijdschrift  voor  Geneesk.,  li,  p.  721,  1902. 

•  Deutsch.  Archiv.  f.  klin.  Med.,  xciii,  p.  86,  1905;  also  Berlin,  klin. 
Wochenschr.,  No.  i,  p.  7,  1906. 


meteorism;  tympanites  451 


METEORISM;  TYMPANITES 


This  is  defined  as  an  accumulation  of  gas  in  the  intestines. 
Flatulence  is  used  to  indicate  a  great  formation  of  gases  that  are 
removed  by  eructations  and  flatus. 

Part  of  the  gas  thus  accumulated  is  expelled  and  part  is  absorbed, 
and  thus  the  volume  of  gas  in  the  intestines  is  regulated. 

Etiology. — The  causes  of  tympanites  are  as  follows: 

1.  An  increased  introduction   (ingestion)  of  gas. 

2.  The  development  of  excessive  gas  within  the  intestines. 

3.  A  diminution  or  impairment  of  the  eliminative  power  of  the 
intestines  for  gases. 

1.  The  increased  introduction  of  gases  may  be  due  to  the  excessive 
drinking  of  aerated  beverages  or  the  swallowing  of  air. 

Aerophagy  (air  swallowing)  usually  occurs  in  hysteric  women, 
and  may  result  from  shock  or  emotional  disturbance.  It  is  generally 
involuntary,  due  to  spasm  of  the  pharynx.  The  symptoms  are 
distention  after  food,  loss  of  appetite,  frequent  noisy  eructations, 
often  insomnia  or  sleeplessness,  constipation.  Frequently  mucous 
colic  or  gastroptosis  (enteroptosis)  coexist.  Rapid  deglutition' 
movements  precede  the  eructations. 

The  mucous  colic  or  enteroptosis  should  be  treated ;  the  hysteria 
combated;  pharyngeal  spasm  checked  by  keeping  the  mouth  widelyi 
open,  applying  cocain  (i  per  cent.)  locally,  blisters  externally,  bella- 
donna, bromids,  or  valerian  internally;  hypnotic  suggestion  in  some 
cases;  strychnin  to  stimulate  the  muscular  tone  of  stomach;  food; 
should  be  concentrated. 

2.  Formation  of  Abnormal  Quu.ntity  of  Gas  in  the  Intestines. — ^This: 
may  be  due  to  fermentation  of  the  carbohydrates  or  to  putrefaction 
of  the  proteids.  An  excessive  amount  of  fermentable  or  putrefactive 
material  or  food  which  cannot  be  assimilated  are  factors.  Catarrhal 
conditions  influence  the  activity  of  the  ferment  and  putrefactive 
organisms. 

3.  Diminished  Elimination  of  Gases  from  the  Intestines. — This  is 
due  to  mechanical  obstruction  or  to  a  reduction  or  inhibition  (paral- 
ysis) of  the  muscular  power  of  the  intestinal  wall. 

Among  the  causes  are  stenosis,  intestinal  obstruction,  paresis 
of  the  intestines  in  the  infectious  diseases,  such  as  typhoid  fever, 
pneumonia,  cerebrospinal  meningitis,  peritonitis,  etc. 

In  pathologic  conditions,  where  there  is  circulatory  disturbance 
in  the  intestinal  walls,  as  in  peritonitis,  etc.,  absorption  of  gases 
must  be  interfered  with.  It  is  difficult  to  estimate  to  what  degree 
this  is  a  factor. 

Nervous  Meteorism. — This  is  most  common  in  the  hysteric,  and 
usually  occurs  as  a  diffuse  distention  of  the  abdomen  (tympanites 
hystericus),  but  also  as  a  circumscribed  swelling  (phantom  tumor)* 

Various   factors  have  been   suggested,    such   as   swallowed   air^ 


452  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

insufficiency  of  the  pylorus,  allowing  passage  of  air  from  stomach  to 
bowels;  or  continuous  contraction  of  the  diaphragm  (Talma). 

With  narcosis  the  abdomen  becomes  flaccid,  while  with  returning 
consciousness  meteorism  recurs,  and  air  cannot  be  detected  entering 
or  leaving  the  tract,  hence  Talma  denies  that  there  is  any  increase  of 
gas  in  the  intestines.  Some  attribute  the  condition  to  acute  general 
paresis,  of  sudden  onset,  passing  off  rapidly,  analogous  to  other 
hysteric  paralyses. 

Sjonptoms. — The  shape  of  the  abdomen  is  usually  altered,  a 
feeling  of  tension  is  almost  always  experienced.  With  general 
meteorism  the  abdomen  is  distended  quite  symmetrically,  while 
with  partial  distention  the  affected  parts  stand  out  in  marked 
relief. 

With  local  distention  the  coexistence  of  visible  peristalsis,  as 
with  stenosis,  simplifies  the  diagnosis.  The  degree  of  distention 
generally  corresponds  to  the  amount  of  gas  present;  but  the  weaker 
the  muscles  and  the  more  reduced  their  tone,  the  greater  is  disten- 
tion.    An  example  of  this  is  marked  tympanites  in  peritonitis. 

When  the  abdominal  muscles  are  tense  sometimes  the  diaphragm, 
heart,  and  lungs  are  forced  upward,  and  severe  dyspnea  results, 
which  occasionally  may  be  followed  by  a  fatal  issue. 

In  severe  cases  there  is  a  constant  feeling  of  pressure  and  a  desire 
to  pass  wind,  while  colicky  pains  are  sometimes  present.  As  a  rule, 
no  flatus  is  passed,  or  in  inconsiderable  amounts  at  long  intervals. 

Palpation  shows  the  abdominal  walls  are  very  tense.  They 
present  an  air-cushion  resistance.  The  percussion  note  is  abnormally 
low  and  loud,  the  tympanitic  ring  is  usually  lost.  With  auscultatory 
percussion  a  metallic  sound  is  elicited.  The  liver  dulness  may  be 
reduced  and  finally  disappear.  There  are  some  cases  of  meteorism, 
in  which  the  wind  is  passed  almost  constantly  from  the  anus  with 
considerable  noise.  Rosenheim  believes,  as  these  gases  are  odorless, 
that  the  air  is  pumped  into  the  rectum  and  emitted  again  as  flatus. 

Prognosis. — If  occlusion  of  the  intestines  is  present,  the  outlook 
is  serious.     Ordinary  cases  are  favorable. 

Treatment. — This  should  be  directed  toward  removal  of  the 
cause  responsible  for  meteorism,  such  as  peritonitis,  typhoid, 
stenosis,  etc. 

Drinks  and  foods  known  to  produce  flatulence  must  be  prohibited. 
Avoid  carbonated  waters,  beer,  champagne,  cider,  excessive  carbo- 
hydrates, rich  pastry,  etc. 

Intestinal  fermentation  or  intestinal  putrefaction,  if  they  cause 
the  meteorism,  must  he  treated  after  the  methods  already  described. 

Among  the  intestinal  antiseptics  are  ichthalbin,  ichthoform, 
formidin,  salol,  salicylate  of  soda,  benzonaphtol,  urotropin,  and 
sodium  benzoate,  average  dose  of  each,  gr.  5  (0.3)  t.  i.  d.  after  meals. 
They  may  be  given  in  shellacked  capsules.  Bismuth  salicylate  and 
bismuth  subnitrate,  gr.  5  to  10  (0.3-0.6)  t.  i.  d.,  are  of  service. 


INTESTINAL   PAIN    (INTESTINAL    COLIC;    ENTERALGIA)  453 

Calcined  magnesia,  lime-water,  and  charcoal  are  suggested  to 
absorb  the  gas. 

In  mild  forms  of  flatulency  various  carminatives  have  been 
employed,  such  as  caraway  seed,  peppermint,  mint,  thyme,  cinnamon, 
cloves,  anise  seed,  nutmeg,  sassafras,  and  fennel.  These  are  best 
given  as  infusions.  Asafetida  and  the  oil  of  cloves  are  believed  by 
Brunton  to  aid  absorption  of  CO2  and  H2S. 

Cathartics  and  laxatives  may  be  necessary  when  there  is  no 
peritonitis  or  obstruction.  Physostigmin  salicylate,  gr.  joq-  to  -g-'g 
(0.0006-0.001),  has  been  recommended  in  severe  cases. 

Massage,  abdominal  douches,  electricity,  and  electric  enterocl3"sis 
are  of  service  in  cases  where  there  are  no  anatomic  lesions.  Friction 
of  the  abdomen  with  spiritous,  aromatic,  or  ethereal  substances, 
such  as  camphorated  oil,  turpentine,  oil  of  cajeput,  etc.,  is  serviceable. 

The  introduction  of  a  colon-tube  may  aid  the  escape  of  gas. 
Water  enemata  of  soapsuds,  containing  spirits  of  menth.  piperit.,  Zj 
(4.0),  or  oil  of  turpentine,  3j  (4.0),  are  useful. 

Puncturing  the  intestines  with  a  trocar  is  a  dangerous  procedure. 

Meteorism  in  the  hysteric  occasionally  disappears  without 
treatment.  Attention  should  be  paid  to  the  nervous  condition. 
Valerian  and  asafetida  are  useful  by  mouth  or  enema  in  such  cases. 

Pill  asafet.,  one  t.  i.  d. ;  emulsion  (milk)  asafet.,  oj  to  ij  (30.0- 
60.0),  by  enema. 

Zinc  valer.,  gr.  2  (0.125),  or  ammon.  valer.,  gr.  5  (0.3),  t.  i.  d. 

Tinct.  valer.  with  tinct.  lavend.  co.,  da  oij  (60.0).  Dose,  3j  (4.0) 
in  water  t.  i.  d.  after  food.  Iron,  arsenic,  and  strychnin  are  of  tonic 
value  in  the  nervous  cases. 

Massage,  friction,  and  a  tight  abdominal  band  are  useful. 

INTESTINAL  PAIN   (INTESTINAL  COLIC;  ENTERALGIA) 
Intestinal  pain  can  be  distinguished  as  follows: 

1.  Pain  originating  from  inflammation  of  the  intestinal  wall  or 
of  its  peritoneal  coat. 

2.  Pain  of  colic. 

3.  Nervous  enteralgia,  described  under  Neuroses. 

Colic  is  the  painful  stimulation  of  the  intestinal  ner\^es  which 
is  produced  by  severe  tonic  contractions  of  the  intestines.  G.  F. 
Shiels^  holds  that  the  pain  is  produced  in  the  peritoneal  coat. 
Kast  and  Meltzer  have  demonstrated  by  a  series  of  experiments  that 
the  intestines  are  sensitive  to  pain. 

Etiology. — Organic  lesions  of  the  intestines,  excess  in  or  improper 
articles  of  food, cold  drinks,  substances  causing  marked  gas  formations, 
fecal  accumulation,  intestinal  worms,  foreign  bodies,  gall-stones,  enter- 
oliths, tainted  foods,  large  quantities  of  mucus,  as  in  mucous  colic,  ex- 
posure to  cold, occasionally  ulcers,  internal  strangulation  of  the  bowels, 
■stenosis,  purgatives,  lead-  and  copper-poisoning  may  produce  colic. 
1  American  Journal  of  Surgery,  April,  1908. 


454  DISEASES   OF  THE   STOMACH  AND  INTESTINES 

S3rmptoms. — The  pain  of  colic  is  peculiar — pinching,  boring,  or 
occasionally  of  a  tearing  character — it  occurs  in  paroxysms  which 
msLj  last  a  few  seconds  or  be  prolonged  several  hours.  It  usually 
appears  suddenly  and  disappears  as  rapidly.  Its  intensity  may  be 
so  severe  that  fainting  and  collapse  occur. 

If  cohc  begins  from  error  in  diet,  there  may  be  gastric  disturb- 
ances, belching,  nausea,  and  vomiting.  Obstinate  constipation  and 
•  flatulence  may  be  present,  or  if  the  cause  be  from  improper  food, 
diarrhea.  The  pain  frequently  starts  at  the  umbiUcus  and  remains 
localized  or  radiates  in  other  directions.  The  face  of  the  patient 
shows  his  suffering.  Pressure  over  the  abdomen  relieves  the  pain 
in  some,  while  in  others  it  increases  it.  There  may  be  straining 
sensations  in  the  bladder  and  rectum  and  occasionally  borborygmi 
can  be  heard.  Peristaltic  movements  can  be  seen  in  thin  patients. 
If  accumulated  fecal  masses  and  gas  are  evacuated  spontaneously 
or  by  injections,  the  attack  rapidly  subsides. 

Spastic  contractions  of  the  intestines  may  be  encountered.  If 
they  involve  a  large  part  of  the  bowels,  as  in  lead-colic,  the  abdomen 
appears  trough  shaped.  In  stercoral  and  wind-colic,  it  is  usually 
tympanitic. 

Diagnosis. — In  enteralgia  due  tp  anatomic  lesions  of  the  intes- 
tines the  pain  is  increased  by  pressure.  There  is  frequently  diarrhea 
and  the  stools  contain  blood,  mucus,  and,  rarely,  pus. 

With  rheuriiatism  of  the  abdominal  muscles  the  pain  is  superficial 
and  not  within  the  abdominal  cavity.  It  often  changes  its  location. 
Pressure  increases  the  pain,  while  rest  and  antirheumatic  medicines 
diminish  it. 

With  peritonitis  there  are  fever,  tenderness  on  pressure,  muscular 
rigidity,  meteorism,  absence  of  abdominal  respiration,  increase  of 
polynuclears,  and  leukocytosis. 

Hyperesthesia  of  the  abdominal  wall  usually  occurs  in  hysteria 
and  neurasthenia.  The  pains  are  superficial,  lying  chiefly  in  the 
skin.  The  faradic  current  often  removes  the  pain.  Biliary  and 
renal  colic  are  recognized  by  location  of  the  pain  and  characteristic 
symptoms.     Neuralgic  pains  are  superficial  and  radiate. 

Prognosis. — These  cases  end  in  recover}^,  with  rare  exceptions. 

Treatment. — For  the  relief  of  pain,  morphin  by  hypodermic, 
gr.  i  to  I  (0.008-0.016),  or  codein,  same  or  even  double  dose,  or 
tincture  of  opium,  TTLx  (0.59  cc),  heat  to  the  abdomen,  and  hot  saline 
enema  or  enteroclysis  at  115°  F.     Squibb's  mixture  is  useful. 

Later,  the  bowels  should  be  thoroughly  evacuated  by  enemata^ 
which  may  contain  h  pint  (250  cc.)  of  olive  oil  and  oj  (4.0)  of  spirits 
of  turpentine,  and  a  cathartic — castor  oil,  .5iss  (45.0),  or  calomel,  gr.  5 
(0.3) — be  given,  followed  by  a  saline  cathartic. 

The  cause  of  the  colic  should  be  corrected,  as  should  any  errors  in 
diet.     Fluid  diet  should  be  employed. 

1  The  simple  soapsuds  enema,  i  quart  (liter). 


VISCERAIv  ARTERIOSCLEROSIS  455 

VISCERAL  ARTERIOSCLEROSIS 

Harlow  Brooks^  calls  to  our  attention  that  the  presence  of  dimin- 
ished visceral  function,  with  occasional  and  otherwise  unaccountable 
elevations  of  the  blood-pressure,  should,  particularly  in  connection 
with  possible  etiologic  factors,  lead  to  a  suspicion  of  some  localized, 
if  not  general,  area  of  arterial  disease.  When  associated  with 
pain  of  peculiar  anginal  character,  location  in  some  special  organ 
may  be  within  the  range  of  possibility.  I  feel  quite  certain  that 
careful  observ^ation  of  cases  of  obscure  abdominal  pain,  paroxvsmal 
in  character  and  associated  with  elevation  of  the  blood-pressure, 
will  eventually  make  it  possible  to  diagnose  these  generally  unrecog- ' 
nized  types  of  arterial  disease  while  in  a  stage  when  something  may 
still  be  done  for  their  alleviation  or  for  the  prevention  of  their  further 
progress.  ^ 

Some  of  these  patients  give  a  history  of  nervousness,  gastric 
catarrh,  and  pain;  vomiting  and  even  hematemesis  may  occur. 
iVIeteorism  and  constipation  are  not  uncommon.  Pain  over  the 
pancreas  and  intestinal  functional  disturbances  have  been  noted. 
When  such  symptoms  occur  in  a  patient  with  well-marked  arterio- 
sclerosis, and  are  relieved  by  iodids  and  nitrates,  one  is  justified  in 
diagnosing  abdominal  arteriosclerosis. 

Etiology. — Alcohol,  nephritis,  syphilis,  old  age,  tuberculosis, 
tobacco  excesses,  and  toxemia  are  the  chief  causes. 

Perutz-  shows  we  must  differentiate  between  angina  pectoris 
and  angina  abdominis  due  to  arteriosclerosis: 

1  have  recently  seen  several  cases  who  have  complained  of 
pain  in  the  epigastrium,  belching,  constipation,  and  headache.  The 
gastric  analysis  showed  deficient  hydrochloric  acid  secretion  and  the 
pulse  the  characteristics  of  arteriosclerosis.  Treatment  afforded 
no  relief  until  the  nitrites  were  administered.  "  Gilbride^  reports  a 
number  of  cases  with  symptoms  of  pain  in  the  epigastric  or  umbilical 
regions,  rarely  in  the  lower  abdomen.  This  is  increased  by  exertion 
and  in  some  cases  during  digestion.  Weakness,  loss  of  weight, 
abdominal  distention,  and  belching  are  present.  Bowels  are  con- 
stipated or  there  is  constipation  alternating  with  diarrhea,  or  occa- 
sionally normal  movements.  There  may  be  vertigo  or  disturbances 
of  vision.  The  gastric  analysis  showed  in  most  cases  deficiency  of 
hydrochloric  acid;  in  one  it  was  nearly  absent  and  in  one  normal. 
Stomach  motiHty  normal  or  increased.  Lactic  acid  and  Boas- 
Oppler  bacilli  were  absent.  Cancer  had  been  suspected.  The 
radial  pulse  and  blood-pressure  may  show  arteriosclerosis.  In  some 
cases  there  are  no  evidences  of  this,  but  there  are  two  symptoms 

^  American  Journal  of  the  Medical  Sciences. 

2  Miinch.  med.  Wochenschr.,  !\Jay  2S  and  June  4,  1907. 

3  Gast  ro-intestinal  Disturbances  Due  to  Arteriosclerosis,  Journal  Amer.  Med. 
Assoc,  March  20,  1909. 


456  DISEASES   OF   THE   STOMACH  AND   INTESTINES 

significant  of  abdominal  arteriosclerosis — tenderness  of  the  abdominal 
aorta  with  epigastric  pulsation.  Some  patients  may  have  attacks 
of  angina  pectoris  with  pain  referred  to  the  epigastrium.  The  age 
of  the  patient  is  usually  over  forty."  Ortner^  has  contributed  to  the 
subject,  demonstrating  the  disturbances  of  the  motor,  secretory,  and 
absorptive  functions  of  the  intestines  due  to  arteriosclerosis;  and 
Akin^  has  reported  several  cases.  Nitrites  afford  the  most  relief, 
with  the  addition  of  potassium  or  sodium  iodid. 

ANOMALIES  IN  THE  POSITION  AND  FORM  OF  THE  INTESTINES ; 

ENTEROPTOSIS 

Various  anomalies  in  the  position  and  form  of  the  intestines  occur ; 
in  some  cases  congenital,  and  in  others  acquired,  of  which  Koch  and 
Curshman  have  made  a  study. 

They  may  be  congenital  in  some  cases,  acquired  through  copros- 
tasis,  the  weight  of  a  tumor,  or  the  formation  of  adhesions,  in  the 
majority  of  cases  the  colon  being  affected.  Various  angulations  of 
the  sigmoid,  especially  due  to  adhesions,  are  described  by  J.  P. 
Tuttle.  Inflation  with  air  and  the  use  of  bismuth  injections  with 
the  x-rays  aid  diagnosis. 

Hirschsprung's  disease,  or  congenital  primary  dilatation  and 
hypertrophy  of  the  colon,  is  found  at  birth.  Dyspeptic  symptoms, 
obstinate  constipation,  and  colicky  pains  with  great  distention  are 
present.  By  insertion  of  a  finger  or  catheter  into  the  rectum  a 
movement  will  occur  with  relief  of  the  distention.  Enterocl^^sis, 
electricity,  etc. ,  are  of  value. 

Idiopathic  dilatation  of  the  colon  is  a  rare  event,  and  enteroptosis, 
the  most  common  displacement,  is  described  under  Gastroptosis. 

Idiopathic  dilatation  of  the  colon,  in  which  there  is  no  mechan- 
ical obstruction  to  the  feces,  mav  be  congenital,  develop  early  or 
later  after  birth,  or  be  acquired  in  adult  life.  Ner\^ous  derange- 
ments, habitual  constipation,  rickets,  or  chronic  colitis  may  be  fac- 
tors. The  colon  and  especially  the  sigmoid  are  greatly  distended, 
so  that  the  protrusion  of  the  abdomen  may  justify  the  term  "  bal- 
loon man."  Constipation  or  irregularity  of  the  bowels,  gaseous  dis- 
tention, intestinal  putrefaction,  shortness  of  breath,  etc.,  occur. 
Enteroclysis,  regulation  of  the  bowels,  diet,  and  treatment  of  indi- 
canuria  are  indicated.  Abdominal  support  is  of  service.  Rarely, 
operative  procedure  is  required. 

INTESTINAL  SAND 

This  material  is  gritty,  contains  organic  matter,  inorganic  salts, 
especially  calcium  phosphate  and  carbonate,  but  no  cholesterin,  which 
distinguishes  it  from  biliary  sand. 

1  Volkmann,  Samml.    klin.  Vortr.,  No.  347. 

2  Jour.  Amer.  Med.  Assoc,  June  5,  1909. 


INTESTINAL   SAND  457 

It  has  been  considered  by  some  as  a  manifestation  of  the  arthritic 
diathesis.  It  is  usually  associated  with  mucous  colic  or  possibly 
constipation.  It  occurs  generally  in  women  between  thirty  and  forty 
years  of  age. 

The  associated  condition  must  be  treated.  Sodium  bicarbonate 
and  bismuth  salicylate  have  been  recommended. 

False  intestinal  sand,  such  as  the  residue  of  vegetable  food, 
especially  from  pears,  must  not  be  mistaken  for  true  sand.  Symp- 
toms are  absent. 


CHAPTER  XXII 
CONSTIPATION  AND  DIARRHEA 

CONSTIPATION 

{Synonyms. — Obstipatio  Alvi;  Constipatio  Alvi;  Atony  of  the  Bowel;  Habitual 

Constipation.) 

HeaIvThy  persons  usually  have  one  bowel  movement  daily,  gen- 
erally about  the  same  hour-  Some  normally  have  two  actions  a 
day,  while  others  empty  the  bowels  every  other  or  every  second 
day,  and  yet  are  in  perfect  health. 

Constipation  is  defined  as  a  condition  in  which  the  feces  are  not 
passed  sufficiently  often.  Another  form  is  that  in  which  defecation 
occurs  daily,  but  the  movements  are  insufficient  in  quantity.  A 
stagnation  of  fecal  matter  may  thus  occur.  The  quantity  of  feces 
is  somewhat  variable,  from  loo  to  150  gm.,  the  average,  even  up  to 
250  gm.,  being  greater  after  a  vegetable  diet  and  less  after  meats. 

Considerable  of  the  evacuation  is  made  up  6i  micro-organisms, 
of  which  Herter^  has  estimated  the  daily  number  as  126,000,000,000, 
which  explains  the  fact  that  patients  who  eat  little  may  pass  con- 
siderable material. 

Constipation  may  be  acute  or  chronic.  The  acute  type  is  due  to 
complete  obstruction  of  the  intestinal  tract  or  to  dynamic  ileus 
(intestinal  paresis). 

The  chronic  type  is  extremely  common.  Henry  Illoway  and 
Samuel  Gant  have  written  excellent  works  on  this  subject.  My 
classification  is  slightly  modified  from  their  books. 

Etiology. — All  possible  factors  must  be  carefully  investigated. 

1.  Diseases  of  the  stomach,  such  as  hyperchlorhydria,  ulcer, 
cancer,  dilatation,  simple  atony,  catarrhal  conditions,  and  achylia 
gastrica  may  cause  constipation. 

2.  Obstruction  of  the  bowel  by  tumors  of  the  intestine  or  tumors 
pressing  on  the  bowel  from  some  adjacent  organ ;  by  stricture  within 
the  intestine;  by  external  stricture,  as  by  peritonitic  adhesions;  by 
chronic  intussusception. 

3.  Catarrh  of  the  small  intestine  alone;  in  some  cases  catarrh  of 
the  large  intestine ;  mucous  colic ;  atrophy  after  catarrh ;  ulcers  of  the 
small  intestine  are  occasionally  attended  by  constipation;  dysenteric 
ulcers  at  times  produce  constipation,  though  ulcers  of  the  large  intestine 
usually  cause  diarrhea. 

4.  Voluntary  abstention  from  stool  on  account  of  the  pain  it  pro- 
duces, by  reason  of  disease  of  the  rectum,  such  as  from  piles,  fissure, 

^  Bacterial  Infections  of  the  Digestive  Tract. 
458 


CONSTIPATION    AND    DIARRHEA  459 

or  ulcer.     Increased  contraction  of  the  sphincter  ani  also  occurs  from 
irritation  and  interferes  with  bowel  action. 

5.  Obstruction  to  the  entrance  of  bile  into  the  intestine  or  deficiency 
of  bile. 

6.  Diseases  of  the  heart,  lungs,  liver,  and  kidneys.  Intestinal 
hyperemia  and  congestion  of  the  portal  system  are  factors  in  these 
cases  in  retarding  peristalsis,  as  in  cirrhosis  of  the  liver. 

7.  Disease  of  the  pancreas. 

8.  Diabetes,  anemia,  and  chlorosis. 

9.  In  many  diseases  of  the  brain,  spinal  cord,  and  of  the  nervous 
system  constipation  is   present. 

Among  such  are  chronic  insanity,  diphtheritic  paralysis,  tabes, 
brain  tumors,  cerebrospinal  meningitis,  hemorrhage  of  the  brain, 
chronic  hydrocephalus,  myelitis,  neuroses,  and  psychoses. 

10.  Acute  febrile  conditions  are  usually  accompanied  by  constipa- 
tion, as  pneumonia,  etc.  This  generally  excludes  those  with  special 
intestinal  lesions.  We  must  remember  that  constipation  occurs  in 
some  cases  of  typhoid,  and  even  of  dysentery. 

1 1 .  Chronic  constipation  from  foreign  bodies. 

12.  Malformations,  such  as  abnormally  developed  colon;  undue 
size  or  length  of  the  sigmoid  flexure ;  diverticula  of  the  large  intes- 
tine; a  diaphragm  partially  closing  the  large  intestine. 

13.  Defective  development  or  essential  primary  atrophy  of  the  colon. 

14.  Enter optosis;  angulations  of  the  sigmoid  flexure  due  to 
adhesions;  prolapse  of  sigmoid  into  rectum  from  long  mesentery — 
in  effect,  slight  intussusception. 

15.  Atrophy  of  the  intestinal  musculature  following  catarrh  or 
fatty  degeneration,  as  in  consumption  or  in  alcoholics. 

16.  Hypertrophy  of  Houston's  valves. 

17.  Loss  of  power  in  the  abdominal  muscles  may  be  a  factor  in  some 
cases,  as  in  the  emaciated,  with  multiparous  women  with  diastasis 
of  the  recti,  etc. 

18.  Chronic  constipation  from  impaired  physiologic  function. 
This  type  is  due  to  disturbance  of  the  motor  function  of  the  intestines, 
and  is  strictly  classified  under  motor  neuroses,  under  which  we  have: 

(a)  Constipation  due  to  retarded  intestinal  peristalsis  (atony  or 
relaxation  of  the  bowel). 

(6)  Spastic  constipation,  perverted  action,  or  enterospasm. 
The  constipation  is  due  to  a  spasmodic  contraction  of  a  portion  of 
the  intestine. 

(c)  Spasm  of  the  sphincter  is  included  under  this  type. 

Constipation  Due  to  Disturbances  of  the  Motor  Function. — Habitual 
constipation  due  to  impairment  of  the  physiologic  function  {i.  e., 
caused  by  motor  disturbances)  constitutes  an  important  class  of 
cases.     It  should  be  strictly  classified  under  motor  neuroses. 

There  are  the  two  types  mentioned  above:  the  atonic  and  the 
spastic  forms  of  constipation. 


460  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

Atonic  Constipation. — Constipation  due  to  atony  (literally,  relaxa- 
tion) of  the  bowels  constitutes  the  majority  of  cases. 

Predisposing  Causes. — The  character  and  quantity  of  food  and 
the  amount  of  physical  exercise  influence  bowel  evacuation.  Boas 
has  laid  stress  upon  the  importance  of  the  type  of  nourishment  and  its 
influence  in  the  production  of  constipation  (alimentary  constipation). 

Albuminous  diet  consisting  of  meat  and  eggs  leaves  little  residue, 
and  eventually  tends  to  constipate;  while  with  vegetable  diet  there 
is  more  residue  and  the  fermentation  products  excite  peristalsis. 
A  patient  may  diet  by  avoiding  vegetables,  butter,  and  fat,  and  thus 
constipation  result  which  may  become  chronic. 

Repeated  neglect  of  the  call  of  nature  is  a  frequent  cause,  such 
as  in  the  case  of  young  girls  and  children  while  at  school,  or  among 
women  at  social  gatherings,  etc. 

Interruption  of  the  habit  of  regularity,  as  on  a  railroad  journey, 
or  an  attack  of  diarrhea  with  subsequent  constipation,  or  of  acute 
fever,  may  lead  to  habitual  constipation.  The  same  is  true  of  mental 
conditions,  such  as  depressing  emotions.  Prolonged  exercise,  such  as 
long  marches,  has  produced  chronic  constipation. 

Constipation  is  more  frequently  found  among  the  wealthy  than 
among  the  working  class.  The  mode  of  living,  sedentary  life,  etc., 
have  a  bearing.  Worry  and  mental  strain  have  an  influence,  and 
it  occurs  among  neurasthenics  and  hypochondriacs. 

Habitual  constipation  is  found  in  those  engaged  in  active  exercise 
and  who  are  of  strong  constitution.  In  such  persons  the  cause  of 
this  perversion  of  motor  function  is  unknown,  but  it  seems  inherent 
to  the  patients  that  the  bowels  respond  slowly  to  stimuli.  In  some 
cases  there  seems  to  be  hereditary  or  congenital  diminution  of  intes- 
tinal peristalsis  (constipation). 

Riegel  observed  cases  in  which  at  autopsy  the  musculature  of 
the  large  intestine  was  abnormally  thin  and  was  probably  congenital. 
In  some  of  these  cases  the  skeletal  muscles  were  strong.  Nothnagel 
described  similar  cases  in  which  the  general  muscular  development 
was  poor.     These  rare  conditions  cannot  be  recognized  intra  vitam. 

Enteroptosis  is  given  as  a  cause  of  chronic  constipation  on  account 
of  the  intestinal  angulation  which  occurs.  This  is  true  in  some  cases. 
The  general  atony^  with  enteroptosis  is  the  chief  factor.  The 
musculature  of  the  stomach,  intestines,  and  also  the  abdominal 
muscles  are  relaxed,  which  have  a  bearing  on  the  production  of 
constipation.  The  abuse  of  cathartics,  and  repeated  distention  of 
the  bowel  from  large  enemata,  may  produce  constipation. 

Spastic  Constipation. — Spasmodic  constipation  of  the  bowels, 
or  enterospasm,  is  produced  by  a  perversion  of  the  motor  function 
of  the  intestine,  taking  the  form  of  a  spasmodic  contraction  of  a 
portion  of  the  intestines,  which  may  involve  both  the  circular  and 
longitudinal  muscles. 

^  Atonia  Gastrica,  Rose  and  Kemp. 


CONSTIPATION   AND    DIARRHEA  46 1 

This  Spastic  condition  may  be  of  variable  duration  and  involve 
different  segments  of  the  intestines.  Fleiner  holds  that  the  con- 
tracted portion  retains  its  contents,  while  others  believe  that  it  is 
nearly  occluded  by  the  spasm,  thus  creating  an  obstacle  to  the 
passage  of  the  intestinal  contents. 

Diffuse  enterospasm  involving  the  small  intestine  occurs  in  spinal 
meningitis,  in  diseases  of  the  pons  and  medulla,  and  in  chronic 
lead -poisoning.  In  these  cases  the  abdomen  is  retracted  like  a 
trough. 

Local  or  circumscribed  enterospasm  is  more  frequent,  and  it 
generally  affects  a  portion  of  the  large  intestine.  The  abdomen 
shows  no  abnormality  on  inspection. 

Spastic  constipation  is  more  frequently  met  with  in  nervous 
persons,  neurasthenics,  the  hysteric,  and  in  those  debilitated  by 
long-continued  disease.  The  constipation  is  quite  obstinate,  lasting 
for  several  days.  The  evacuation  is  somewhat  painful  and  consists 
of  small  balls  (goat  feces)  or  pencil-shaped  fecal  material.  There 
are  spasmodic  pains  in  the  left  lower  abdomen  or  in  the  umbilical 
region  which  are  relieved  by  the  passages. 

Spasm  of  the  Sphincter  (Proctospasmus). — This  condition  really 
belongs  to  spastic  constipation.  There  is  painful  spasmodic  con- 
traction of  the  sphincter.  I  have  seen  cases,  however,  in  which  pain 
was  not  marked,  but  spasm  occurred  when  defecation  was  attempted; 
in  effect,  spasmodic  stricture  was  present.  Such  cases  may  be  a 
direct  factor  in  the  production  of  constipation. 

Many  cases  of  sphincteric  spasm  are  secondary  to  fissure  or  ulcer 
of  the  rectum,  or  are  reflex  when  there  are  inflammatory  conditions 
in  the  neighboring  organs,  such  as  the  uterus,  bladder,  etc.  Some 
cases  occur  as  a  primary  nervous  affection  and  are  chiefly  met  with 
in  those  with  a  nervous  taint  or  disease  of  the  spinal  cord. 

Rectal  examination  is  often  extremely  painful.  In  some  cases 
there  is  simply  reflex  spasm  on  examination,  and  the  sphincter  is 
found  to  be  extremely  tight  and  evidently  hypertrophied  from 
frequent  contraction. 

-  It  is  important  to  consider  the  possibility  of  the  last  type  in 
connection  with  chronic  constipation. 

Symptoms. — In  many  cases  constipation  causes  no  subjective 
symptoms.  Some  have  a  stool  every  second  or  third  day  or  even 
once  a  week.  There  is  a  classical  case  who  had  an  annual  movement. 
Nevertheless,  chronic  constipation  should  not  be  made  light  of. 

Some  patients  on  the  appearance  of  constipation  immediately 
suffer  from  subjective  symptoms,  which  may  become  at  times  quite 
severe.  Among  milder  symptoms  are  sensations  of  fulness,  tension, 
and  discomfort  in  the  abdomen;  at  times  they  are  referred  to  the 
stomach;  loss  of  appetite,  occasionally  belching,  nausea,  pyrosis, 
and  a  disagreeable  taste  in  the  mouth.  Coated  tongue  and  headache 
are  often  present.     Colicky  pains  and  distention  may  occur. 


462  DISEASES   OF  THE   STOMACH   AND   INTESTINES 

These  symptoms  disappear  after  thorough  evacuation  of  the 
bowels. 

On  inspection  and  palpation  considerable  fecal  accumulation 
can  be  found  in  the  intestines,  especially  in  the  colon.  Some  patients 
suffer  from  severe  headache,  dizziness,  sleeplessness,  despondency, 
palpitation,  tachycardia,  or  irregular  pulse.  Such  symptoms  I 
believe  due  to  auto-intoxication  from  the  intestinal  tract.  Motor 
insufficiency,  as  in  constipation,  favors  stagnation  and  putrefactive 
changes. 

Duprey^  reports  extreme  cases  in  whicTi  the  patients  became  un- 
conscious, but  recovered  after  free  bowel  evacuation.  One  death 
also  occurred. 

In  most  of  my  patients  suffering  from  chronic  constipation,  with 
the  symptoms  just  described,  especially  with  nervous  manifestations, 
marked  indicanuria  was  present. 

Herter^  states  that  most  children  and  many  adults  may  fail  to 
develop  indicanuria  with  constipation,  yet  there  are  others  in  whom 
it  is  marked,  and  that  a  satisfactory  explanation  is  not  possible. 

In  my  report  of  13  cases  of  dementia  paralytica  before  the 
American  Medicopsychologic  Association^  marked  constipation  was 
noted  in  all  the  cases,  and  all  suffered  with  considerable  temperature. 
Rectal  irrigation  lowered  the  temperature  in  3  cases,  and  under 
general  treatment  for  the  gastro-intestinal  tract  it  was  lowered  in 
8  more.  Convulsions  diminished  in  5  cases.  The  bowels  were  freely 
opened. 

Bouchard's  theory  that  no  intoxication  from  the  intestinal  tract 
can  take  place  when  the  feces  are  solid,  I  believe  untenable.  Dunin 
has  shown  that  constipation  may  be  the  result  of  nervous  conditions. 
There  are  many  in  which  no  nervous  factor  can  be  discovered,  and 
others  in  whom  constipation  and  intestinal  auto-intoxication  are 
factors  in  the  production  of  nervous  symptoms. 

Termination. — The  bowels  may  act  spontaneously,  hard  masses 
of  fecal  matter  being  passed  covered  with  a  thin  layer  of  mucus. 
Feces  are  often  passed  in  small  balls  or  in  rod  shape.  With  the 
atonic  type  of  constipation  relief  is  usually  felt  after  defecation; 
while  with  the  spastic  type  movement  is  accomplished  with  great 
effort,  and  there  is  a  feeling  as  if  there  were  still  material  in  the 
rectum. 

In  some  cases  the  constipation  terminates  in  an  attack  of  diarrhea 
due  to  hyperemia  and  the  secretion  of  fluid  from  irritation  of  the 
mucosa  by  the  hardened  feces.  In  others,  purgatives  or  enemata 
may  be  required,  or  removal  of  scybalge  from  the  rectum  by  the 
fingers. 

^Lancet,  1902,  p.  1832. 

2  Bacterial  Infections  of  the  Digestive  Tract,  p.  263. 

^  Proceedings  of  the  Sixty-first  Annual  Meeting,  April,  1903.  Some  observa- 
tions on  the  Relations  of  the  Gastro-intestinal  Tract  to  Nervous  and  Mental 
Diseases. 


CONSTIPATION    AND    DIARRHEA  463 

Slight  catarrh  may  occur  or,  rarely,  stercoral  ulcers,  local  peri- 
tonitis, or  even  perforation  and  general  peritonitis.  Constipation 
has  been  a  factor  in  the  production  of  typhlitis,  diverticulitis,  catarrh 
of  the  cecum  with  secondary  catarrhal  appendicitis,  volvulus,  and 
subacute  or  acute  intestinal  obstruction. 

Fecal  Colic. — ^When  large  masses  of  fecal  matter  accumulate, 
colic  may  occur.  The  patient  is  seized  with  violent  colicky  pains 
which  may  cause  a  fainting  spell.  The  abdomen  is  distended  and 
tender.  Passage  of  flatus  brings  temporary  relief.  The  symptoms 
do  not  disappear  until  thorough  evacuation  of  the  fecal  accumulation 
takes  place.  Fecal  colic  may  occur,  with  daily  evacuation  of  the 
bowels.  The  detection  of  fecal  accumulation  by  palpation  is  of 
chief  importance. 

In  obstinate  cases  of  constipation  cathartics  may  fail  to  produce 
movements  and  the  patient  go  into  marked  collapse  and  vomit 
profusely,  with  symptoms  resembling  intestinal  obstruction.  Rectal 
irrigations  or  oil  injections  may  relieve  the  condition. 

Rarely,  in  the  insane,  old,  or  weak  total  paralysis  of  the  colon 
may  take  place  and  the  patient  die  with  the  symptoms  of  obstruc- 
tion. In  cases  of  fecal  accumulation  it  is  always  safer  to  employ 
injections  and  irrigations  before  resorting  to  active  catharsis. 

Fecal  Tumors. — ^They  occur  most  frequently  in  the  cecum, 
sigmoid  flexure,  rectum,  and  hepatic  and  splenic  flexures.  They 
may  cause  dislocation  of  the  transverse  colon,  and  the  mass  be  felt 
a  short  distance  above  the  symphysis.  In  most  cases  the  tumor  is 
not  of  very  firm  consistency,  is  movable,  and  pits  on  pressure.  On  the 
other  hand,  it  may  be  nodular,  hard,  or  angular. 

In  some  cases  the  bowels  may  move  every  day,  there  evidently 
being  a  free  central  passage. 

Gersuny's  Adhesion  Symptom. — If  the  abdominal  wall  over  the 
tumor  is  gradually  depressed  with  the  finger-tips,  the  pressure  gradu- 
ally diminished,  and  the  fingers  slowly  withdrawn,  one  can  feel 
the  mucous  coat  of  the  intestines  loosening  itself  from  the  feces 
forming  the  tumor  {i.  e.,  the  wall  of  the  bowel  separates  from  the 
tumor  when  palpating  pressure  is  relaxed). 

If  under  intestinal  irrigations,  etc.,  the  tumor  diminishes  in  size, 
it  is  evidently  fecal.  Anesthesia  may  rarely  be  required  for  examina- 
tion. 

Some  of  these  fecal  tumors  have  developed  into  large  size — over 
4  pounds  or  more — and  after  the  colon  is  dilated,  stercoral  ulcers, 
local  or  general  peritonitis,  or  intestinal  obstruction  from  kinking, 
compression,  torsion,  or  internal  occlusion  may  result. 

Hemorrhoids  are  a  complication.  They  are  described  in  a 
special  section. 

I  have  referred  to  various  nervous  symptoms  that  are  dependent 
on  constipation. 

Leube  describes  intestinal  vertigo,  which  he  believes  reflex  and 


464  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

due  to  pressure  on  the  hemorrhoidal  plexuses  of  the  sympathetic, 
since  the  palpating  finger  in  the  rectum  also  produced  it. 

Senator  imputed  dizziness  and  vertigo  to  absorption  of  poisonous 
gases,  such  as  sulphuretted  hydrogen;  while  Nothnagel  assumes 
that  nervous  symptoms  are  due  to  absorption  of  ptomains,  thus 
causing  auto-intoxication. 

Auto-intoxication  I  believe  to  be  the  correct  explanation.  In 
persons  of  a  neuropathic  disposition  auto-intoxication  from  chronic 
constipation  is  undoubtedly  a  contributory  factor  in  the  production 
of  ner^-ous  disease,  especially  melancholia. 

Fecal  Fever. — This  is  generally  due  to  some  complication,  such 
as  inflammation,  local  peritonitis,  or  stercoral  ulcer.  With  infants 
and  young  children  fever  may  be  caused  by  fecal  accumulation. 
I  have  referred  to  the  cases  of  dementia  parahiiica  with  temperature, 
with  disappearance  of  the  latter  after  bowel  action. 

Clark  holds  that  chlorosis  is  the  result  of  toxins  absorbed  from 
coprostasis.  Hyperchlorhydria  is  generally  present  and  this  would 
have  an  influence  on  the  bowels. 

Though  diarrhea  with  marked  multiplication  of  the  Bacillus 
aerogenes  capsulatus  often  occurs  in  common  with  severe  primary 
anemia,  and  in  some  instances  the  cases  present  the  blood-picture 
and  clinical  characteristics  of  pernicious  anemia,  yet  Herter  shows 
that  advanced  infection  with  the  gas  bacillus  can  occur^  without  any 
diarrhea,  in  fact,  with  obstinate  constipation.  Stasis  is  favorable 
to  putrefaction.  The  possibility,  therefore,  of  stasis  (constipation) 
favoring  in  some  cases  the  development  of  poisons  having  a  hemo- 
h^tic  action  on  the  blood  should  be  considered. 

Diagnosis. — The  irregularity  of  the  movements  and  their 
character,  occurring  in  small  balls,  pencil  shape,  or  in  small  fragments, 
and  abdominal  palpation  disclosing  fecal  masses  are  diagnostic- 
One  must  remember  that  daily  incomplete  evacuations  may  occur. 

Fecal  masses  are  found  most  frequently  in  the  caput  coli,  sigmoid, 
and  the  rectum.  It  is  always  well  to  examine  the  latter.  All  possible 
causes  of  constipation  must  be  considered.  If  it  is  suspected  to  be 
due  to  anomahes  of  the  functions  of  the  stomach,  gastric  analysis 
must  be  performed  and  treatment  directed  toward  the  gastric  con- 
dition. 

Diseases  of  the  heart,  lung,  Hver,  and  kidneys  must  be  treated 
if  present.  Rectal  examination  may  disclose  hypertrophy  of 
Houston's  valves;  in  such  event,  their  division  by  the  application  of 
Gant's  valve  clamps  is  indicated. 

Prolapse  of  the  sigmoid  may  be  determined  by  inspection  with 
the  sigmoidoscope.  Gant's  suspensory  operation  is  then  indicated. 
Splanchnoptosis  if  present  must  be  treated  and  Rose's  belt  applied. 

If  none  of  these  causes  can  be  determined,  the  constipation  must 
be  pureh'  functional  (habitual),  either  of  the  atonic  or  spastic  type. 
1  Bacterial  Infections  of  the  Digestive  Tract,  p.  207. 


CONSTIPATION    AND    DIARRHEA  465 

With  atony  of  the  bowels  there  are  sUght  bloating,  evacuation 
of  hard  fecal  matter,  often  in  balls  covered  with  a  thin  layer  of  mucus, 
at  times  dizziness  and  nervous  symptoms.     Severe  pains  are  rare. 

With  enterospasm  there  are  uneasiness  and  pain  at  the  time  of 
evacuation  or  just  preceding  it,  and  at  times  spells  of  faintness. 
The  fecal  matter  is  not  so  hard  and  is  evacuated  after  considerable 
straining  in  narrow  tape-like  or  pencil-shaped  pieces.  There  is  no 
feeling  of  complete  relief  after  evacuation,  but  as  if  more  were 
present.  The  abdomen  may  at  times  be  sunken  and  retracted  and 
the  intestinal  coils  can  sometimes  be  palpated. 

Prognosis. — This  is  favorable  in  the  majority  of  cases  as  regards 
life,  though  occasionally  incurable  lesions,  such  as  diverticulitis, 
ulceration,  or  even  peritonitis  and  death  may  result.  These  compli- 
cations are  comparatively  rare.  The  prognosis  as  to  cure  depends 
on  the  cause  of  the  constipation.  In  the  functional  cases  of  halDitual 
constipation  cures  result,  but  many  cases  require  more  or  less  care 
for  the  balance  of  their  lives. 

Treatment. — General  Methods. — The  cause  of  the  constipation 
should  be  treated.  Persons  who  for  years  have  habitually  had  a 
movement  every  second  or  third  day  and  are  in  good  health  should 
be  let  alone. 

Prophylaxis. — Never  place  a  patient  on  a  restricted  diet  for  too 
long  a  period,  excluding  vegetables,  fruits,  starchy  foods,  and  fats 
which  would  dispose  to  constipation.  Abuse  of  cathartics  should 
be  avoided. 

A  hygienic  method  of  living,  proper  out-of-door  life  and  exercise, 
diminution  of  strain  and  worry  are  necessary.  As  few  purgatives  as 
possible  should  be  employed. 

Training  of  the  Patient. — One  should  allay  the  patient's  anxiety. 
He  should  be  told  not  to  worry  if  the  bowels  fail  to  act  for  a  day  or 
two.  Meanwhile,  rational  methods  should  be  undertaken  by  the 
physician  to  produce  the  desired  result.  Trousseau  first  advocated 
teaching  regularity.  The  patient  should  be  taught  to  endeavor  to 
have  an  evacuation  at  a  regular  time  every  day,  preferably  half  an 
hour  after  breakfast.  He  should  go  to  the  closet  and  try  to  have  a 
passage,  but  should  not  exert  himself  for  over  five  minutes.  It  is  an 
excellent  procedure  to  aid  the  return  to  the  habit  by  insertion  of  a 
small  gluten  or  glycerin  suppository  or,  preferably,  the  injection  of 
I  to  2  ounces  (30.0-60.0)  of  olive  oil  with  a  soft-rubber  hand  syringe. 
This  is  better  than  waiting  twenty-four  hours,  as  the  desire  is  often 
thus  stimulated.  Regular  habits  could  thus  often  be  cultivated  and 
the  small  injection  then  stopped. 

Diet. — The  main  object  is  the  ingestion  of  foods  which  increase 
intestinal  peristalsis  and  the  avoidance  of  constipating  material. 

A  glass  of  cold  water  or,  in  some  cases,  of  hot  water  should  be 
taken  on  rising.  Water  should  be  taken  on  the  fasting  stomach  and 
a  moderate  amount — 5viij  (250  cc.)  at  least — of  fluid  at  meals. 
30 


466  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Total  abstinence  from  liquid  at  meals  tends  to  constipate.  The 
following  are  of  value:  buttermilk,  cider,  sour  milks,  fermented  milk, 
such  as  lactone-milk,  kumyss,  matzoon,  bacillac,  carbonated  waters, 
raw  fruits,  such  as  grapes,  oranges,  grape-fruit,  apples,  prunes, 
pears,  peaches,  plums,  mandarins,  gooseberries,  currents,  straw- 
berries, raspberries,  blackberries;  cooked  fruits,  honey,  lemonade, 
vegetables  rich  in  cellulose,  cabbage,  cucumbers,  spinach,  green 
peas,  cauliflower,  green  salads,  syrup,  sugar,  salmon,  sardines, 
herring,  rye  bread,  Graham  bread,  brown  bread,  pumpernickel; 
fatty  and  highly  seasoned  foods,  plenty  of  butter,  cream.  Excess 
of  potatoes  or  rice  constipate.  Oatmeal  is  often  of  value.  ]\Iilk  is 
constipating  with  some  and  purgative  with  others.  Whortleberries 
are  constipating.  Red  wines,  tea^  chocolate,  and  cocoa  should  be 
avoided.  Beer  and  champagne  are  recommended  by  some.  Chicken 
and  red  meats  are  given  in  moderation. 

We  may  say  the  diet  should  be  mixed,  with  a  preponderance  of 
vegetable  food.  Some  patients,  of  course,  have  idiosyncrasies  to 
certain  foods,  and  one  would  not  give  a  patient  with  a  deUcate 
stomach  cabbage,  cider,  and  brown  bread.  If  the  intestines  are 
already  overburdened  with  too  much  ballast  and  excess  of  cellulose 
has  been  given,  such  articles  must  be  restricted. 

The  internal  administration  of  olive  oil,  oj  to  ij  (30.0-60.0)  or 
more,  has  often  an  excellent  effect;  to  be  given  once  or  twice  daily. 

If  fermentative  or  putrefactive  processes  are  present,  they  must 
receive  attention. 

In  very  obese  patients  one  would  not  give  excessivel}^  fattening 
food.  Often  a  few  prunes  with  the  morning  glass  of  water  and  fruit 
for  breakfast  are  sen.aceable.  The  administration  of  a  raw  apple 
thoroughly  masticated  at  9  p.  m.,  and  an  hour  later  a  large  glass  of 
Vichy,  as  suggested  by  Lewis  K.  Neff,  I  have  often  found  valuable, 
a  morning  movement  resulting. 

Physical  Methods. — These  are  useful  to  strengthen  the  bowel  and 
promote  better  action  or  to  directly  stimulate  peristalsis. 

Alassage. — This  is  of  use  in  the  atonic  cases,  but  not  as  much  so 
in  spastic  constipation.  It  should,  preferably,  be  administered  by 
an  expert  and  the  treatment  carried  out  for  many  months. 

Abdominal  massage  should  be  carried  out  in  the  course  of  the  colon 
by  short  tapping  motions  (vibratory),  or  by  kneading  and  rubbing. 
It  is  preferable  to  massage  from  the  caput  coli  to  the  sigmoid.  The 
small  intestine  should  also  be  manipulated  as  well  as  the  abdominal 
muscles. 

Illoway^  recommends  massage  for  five  to  fifteen  minutes  in 
adults  and  three  to  five  minutes  for  children,  at  least  every  other 
day  for  a  period  of  six  weeks,  and  then,  if  there  is  improvement,  at 
longer  intervals,  but  for  a  long  period  of  time.  It  should  be  given 
preferably  early  in  the  morning  in  the  fasting  condition. 
^  Constipation  in  Adults  and  Children. 


CONSTIPATION   AND    DIARRHEA 


467 


Automassage. — The  patient  sitting  upright  with  the  right  hand 
should  stroke  the  abdomen  from  the  caput  coU  to  the  hepatic  flexure, 
and  then  along  che  transverse  colon.  With  the  left  hand  he  can  then 
massage  down  the  descending  colon.  Circular  stroking  movements 
should  then  be  made  over  the  median  abdominal  region.  I  often 
have  the  patient  follow  this  out  while  endeavoring  to  have  the 
morning  defecation.     Seances  should  last  about  five  to  ten  minutes. 

Cannon-ball  Massage. — A  3-  to  5-pound  cannon-ball  rolled  over 
the  abdomen  in  the  course  of  the  colon  and  small  intestine  spir- 
ally is  of  value.  The  patient  can  employ  this  in  the  dorsal 
position. 

The  hollow  wooden  cannon-ball  with  a  screw  cap,  arranged  so  that 
shot  can  be  placed  therein,  and  thus  different  weights  employed  with 
the  same  ball,  is  an  excellent  instrument  (Fig.  200).  It  is  arranged 
with  a  handle  and  frame  so  that  it  can  be  more  easily  manipulated 


Fig.  200. — Cannon-ball  with  screw  cap.  Fig.  201. — Cannon-ball  with  handle. 


(Fig.  201).  One  should  begin  with  a  weight  of  2  pounds  and  increase 
it  gradually  to  5  pounds. 

Vibratory  Massage. — This  is  of  great  value.  Special  vibration 
should  be  given  over  the  sigmoid  flexure.  The  Vedee  can  be  used 
alone  or  with  electricity.  Seances  should  last  about  ten  to  fifteen 
minutes  in  the  course  of  the  colon  and  over  the  small  intestine. 

Hot  and  Cold  Massage  Electric  Roller. — This  instrument  has  been 
described  and  can  be  employed  for  the  atonic  cases. 

Gymnastic  Exercises. — Exercises  which  bring  the  abdominal 
muscles  into  play  are  of  value,  such  as  gymnastics  on  the  horizontal 
bar,  horseback  riding,  hill  climbing,  skating,  rowing,  bicycling,  golf, 
tennis,  boxing,  fencing.  Overexertion  and  too  abundant  sweating 
should  be  avoided.  Flexion  and  extension  of  the  body  and  lateral 
rotation  while  in  the  sitting  posture;  bending  downward  and  then 


468  DISEASES    OF   THE    STOMACH   AND   IXTESTIXES 

Upward  in  the  standing  position  with  the  knees  held  stiff;  Swedish 
movements  and  treatment  by  the  Zander  methods  are  all  of  value. 

Electricity. — Percutaneous  electricity,  especially  faradization  over 
the  abdomen,  is  useful  as  an  adjunct.  The  intrarectal  method  (one 
electrode  in  the  rectum  and  the  other  over  the  abdomen)  is  recom- 
mended, especially  galvanization. 

The  author's  method  with  recurrent  electric  irrigation  is  practical. 
With  a  glass  Y  attachment  and  two  fountain  syringes,  alternate  hot 
and  cold  electric  douches  can  be  employed  for  the  atonic  condition. 
I  have  used  both  the  faradic  and  galvanic  current.  In  obstinate 
cases  of  high  impaction  I  have  found  hot  normal  saHne  douches  at 
120°  F.  with  the  faradic  current  most  efficacious,  duration  fifteen  to 
thirty  minutes. 

Kussmaul  has  suggested  one  electrode  in  the  stomach  and  the 
other  in  the  rectum. 

Electricitv  is  indicated  in  the  atonic  cases.  Static  electricity 
is  also  recommended.  Doumer^  has  employed  it  in  the  form  of  sparks, 
especially  in  the  left  iUac  fossa. 

Hydrotherapy. — Frictions,  cold  douches,  the  alternating  cold  and 
w'arm  fan  douches,  Scotch  douches,  short  cold  sitz-baths  (five  minutes 
at  12°  C),  the  wet  binder  (Neptune's  girdle)  applied  over  night,  and 
the  Priessnitz  compress  are  all  recommended.  Hydrotherapy  must 
needs  be  conducted  at  a  sanatorium. 

For  practical  purposes  the  sitz-bath  and  wet  abdominal  compress 
suffice  the  general  practitioner. 

Injections;  Enteroclysis. — Recurrent  enteroclysis  with  hot  nor- 
mal sahne  solution  at  110°  to  120°  F.  for  fifteen  minutes  three 
times  a  week,  alone  or  combined  with  electricity  (rectal  method)  or 
with  the  alternating  cold  douche  at  60°  F.,  may  prove  of  ser^'ice  in 
the  Yery  obstinate  cases. 

Enteroclvsis  with  flaxseed  tea  has  also  proved  A'aluable. 

The  soapsuds  and  water  enema  alone — Oj  to  i^  quarts  (500-1500 
cc.) — or  with  olive  oil,  oviij  (250  cc),  or  castor  oil,  oj  to  ij  (30.0-60.0), 
included,  or  normal  salt  solution  alone,  may  be  required,  depending 
on  the  conditions. 

Often  a  small  enema  of  normal  saline  or  soapsuds  and  water  of 
Oj  (500  cc),  if  given  with  the  patient  in  the  knee-elbow  position, 
is  more  efficacious  than  the  larger  injections.  The  water  injections 
may  be  employed  at  the  same  hour  daily  for  a  considerable  time. 
The  large  injections,  as  recommended  by  some,  overdistend  the 
already  atonic  intestines.  The  Sims  position  is  excellent  for  the 
injection. 

Klemperer  recommends  the  injection  into  the  bowel  of  small 
quantities  of  water  at  bedtime — only  \  pint  (250  cc.) — and  the  patient 
is  told  to  retain  the  fluid.     It  is  soon  absorbed  and  evacuation  occurs 

1  Annales  d'Electro-Biologie,  1898,  p.  722. 

2  Therapie  der  Gegenwart,  1899,  p.  48. 


CONSTIPATION    AND    DIARRHEA  469 

the  following  morning.     These  injections  are  given  every  night  for 
three  weeks,  and  then  every  other  night. 

Kussmaul  and  Fleiner  employ  an  injection  of  sweet  oil  into  the 
rectum  at  bedtime,  which  is  to  be  retained.  I  believe  it  advisable 
to  start  with  a  small  quantity,  only  oiv  to  vj  (125.0-200.0),  heated 
to  the  temperature  of  the  body  and  slowly  injected  through  a  colon- 
tube  from  a  fountain  syringe.  The  patient  should  retain  the  oil  as 
long  as  possible  (over  night  if  he  can).  Gradually  increase  the  quan- 
tity to  oviij  to  Oj  (250-500  cc),  and  in  obstinate  cases  nearly  to  i 
quart  (liter). 

As  a  rule,  evacuation  follows  the  next  morning.  I  give  the  in- 
jection every  night  for  a  week,  then  every  other  night  for  several 
weeks,  then  twice  a  week,  and,  finally,  once  a  week.  The  treatment 
should  cover  several  months.  This  method  is  recommended  especi- 
ally for  the  spastic  type  of  constipation,  but  I  have  found  it  of  value  in 
other  cases. 

Olive  oil,  oj  to  ij  (30.0-60.0),  by  mouth  once  to  three  times  a  day 
is  a  valuable  adjunct.     Cottonseed  oil  can  be  substituted  by  enema. 

Glycerin  Injections. — Glycerin,  oj  to  ij  (4.0-8.0),  dissolved  in 
Siij  (95.0)  of  water  and  injected  into  the  rectum  is  of  service  in  some 
cases,  or  given  as  a  suppository.     It  is  somewhat  irritating. 

Flatau^  inserts  or  insufflates  into  the  rectum  gr.  15  to  45  (1.0-3.0) 
of  boracic  acid  powder.  Bowel  action  results  one-half  to  three  hours 
later. 

Orthopedics. — I  have  found  Rose's  belt  of  value  in  chronic  consti- 
pation, even  if  no  ptosis  is  present.  It  lends  strength  to  the  ab- 
dominal muscles  and  so  aids  evacuation. 

Medication. — In  many  cases  of  constipation  mild  laxatives  must 
be  employed,  sometimes  only  temporarily.  More  powerful  cathartics 
are  often  required.  In  constipation  of  the  spastic  form,  and  in  the 
atonic  type  with  fecal  impaction,  belladonna  is  of  great  value.  It 
should  be  given  preferably  as  the  tincture,  in  large  doses,  TTLx  to  xv 
(0.592-0.888  cc),  and  pushed  three  or  four  times  a  day,  so  that 
physiologic  symptoms  are  apparent.  In  constipation  due  to  atony, 
strychnin,  gr.  io  to  3V  (0.00108-0.002 1)  t.  i.  d.,  or  tincture  of  nux 
vomica  in  5-  to  lo-drop  doses  are  of  value,  even  if  no  laxatives  are 
given.     They  are  often  combined  with  a  laxative. 

Among  the  milder  laxatives  are  fluidextract  of  cascara  sagrada 
and  the  aromatic  fluidextract  of  cascara,  of  which  the  dose  is  5  j  to  ij 
(4.0-8.0);  extract  of  cascara,  gr.  i  to  5  (0.065-0.324);  laxophen,  a 
solution  of  phenolphthalein,  oj  to  iv  (4.0-16.0);  phenolphthalein 
(purgen),-  gr.  i  to  5  (0.065-0.324)  to  gr.  15  (i.o);  phenolax  (i  to  3 
wafers);  purgatin,  gr.  15  to  30  (1.0-2.0),  which  is  contraindicated  in 
renal  disease. 

1  Berlin,  klin.  Wochensclir.,  1891,  p.  231. 

2  Purgen  tablets  (Bayer),  each  tablet  contains  gr.  \\  (o.i)  of  phenolphthalein; 
each  phenolax  wafer  contains  gr.  1  of  the  same. 


470 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


Ad.  Schmidt^  claims  that  the  internal  administration  of  agar-agar, 
cutting  up  the  straws  into  small  fragments  and  administering  as 
much  as  25.0  gm.  a  day,  aids  in  softening  the  feces  and  also  evacuation. 
He  adds  to  it  25  per  cent,  of  an  aqueous  extract  of  cascara  sagrada. 
Schmidt  recommends  this  combination,  which  is  dispensed  as  "Regu- 
lin,"  as  being  of  value  in  chronic  constipation.  Dose,  i  teaspoonful 
(4.0)  to  a  tablespoonful  (16.0)  or  more,  mixed  with  stewed  apples 
or  mashed  potatoes.     It  can  be  secured  as  tablets. 

Syrup  of  tamarinds,  5j  (4-o),  or  a  sauce  of  tamarinds;  syrup  of 
figs,  5  j  to  ij  (4.0-8.0) ;  compound  licorice  powder,  3j  to  iv  (4.0-16.0). 
This  last  gripes  some  patients.  Olive  oil  by  mouth,  oj  to  ij  (30.0- 
60.0),  several  times  a  day  is  valuable. 

Aloes  does  not  lose  its  effect  even  when  employed  for  a  long  time, 
and  painless  defecation  results.  It  may  be  used  alone  or  in  com- 
bination.    If  hemorrhoids  are  present  I  do  not  advise  it. 

Rhubarb  is  an  excellent  drug.  Pil.  aloes,  dose,  i  to  2  pills  at 
night.  Tinct.  rhei  aromatici,  5ss  to  j  (2.0-4.0).  Tinct.  rhei,  oj  to 
ij  (4.0-8.0).     The  following  are  of  value: 


I^.     Tinct.  nuqs  vomicae oiss  6 

Fl.  ext.  cascara oss  16 

Pulv.  ipecac gf-  iv 

Pulv.  rhei gr.  xv         i 

Sod.  bicarb oiss  6 

Aq.  menth.  piperit q.  s.  giv  125 

Sig. — Shake.     One  to  two  teaspoonfuls  (4.0-8.0)  t.  i.  d.  in  water  after  meals 
as  a  mild  laxative. 


26 


— M. 


B.     Pulv.  rhei       1 

Magnes.  usta  V  aa  3iv  (16.0). — M. 

Sod.  bicarb.  J 
Sig. — One-half  teaspoonful  (2.0)  t.  i.  d.  after  meals. 


^.     Pulv.  aloes gr.  xx 

Ext.  belladonna       "I  aa  gr.  v 

Ext.  nucis  vomicae  J "• 

Ft.  pil.  No.  XX. 
Sig. — One  to  two  pills  at  night. 


3 
3-— M. 


Podophyllin  combinations  are  quite  useful. 


I^.      Podophyllin 

Ext.  physostigmatis  \ aa  gr.  v 

Ext.  nucis  vomicae 
Ft.  pil.  No.  XXX. 
Sig. — One  pill  at  night  and  in  the  morning  if  required. 


3-— M. 


^-     P!|-  colocynthi  corap.  j -  -      _  ^  (^^g  ^ 

Pil.  rhei  comp.  j  o     j  v        ^/ 

Ext.  hyoscyam gr.  ss  (0.032). — M. 

One  pill. 
Sig. — One  pill  before  dinner. 


1  Miinchener  med.  Wochenschr.,  No.  41,  1903. 


CONSTIPATION    AND    DIARRHEA  47 1 

I^-     Aloin gr.  ^  (0.013) 

Strychnin  sulph S^-  is  (0.00108) 

Ext.  belladonna gr.  i  (0.008) 

Pulv.  ipecac gr-  tV  (0.004). — M. 

One  pill. 
Sig. — One  to  two  pills  at  bedtime. 

I^.     Resinse  podophyllin gr.  i  (o.oi  i) 

Pil.  rhei  comp gr.  iiss  (0.162) 

Ext.  hyoscyam gr.  i  (0.032). — M. 

One  pill. 
Sig. — One  to  two  pills  at  night. 

I^.     Ext.  colocynth  comp gr.  j  (0.065) 

Ext.  jalap gr.  ^  (0.032) 

Resin,  podophyllin .gr.  \  (0.016) 

Leptandra gr.  |  (0.32) 

Ext.  hyoscyami  I  ..,,         ^^ 

Ext.  taraxaci      | ^^gr.^  (0.016) 

01.  nienth.  pepmt q.  s. — M. 

One  pill. 
Sig. — One  to  two  pills  at  bedtime. 

Jalap^  and  colocynth  belong  to  the  stronger  remedies,  and  I  only- 
employ  them  temporarily  to  empty  the  bowels.  The  same  is  true  of 
castor  oil  and  calomel. 

Hunyadi,  Friederickshall,  the  Homburg  Waters,  Carlsbad  salts, 
Pluto,  Apenta,  Rubinat,  etc.,  may  be  necessary  for  a  brief  period, 
but  should  not  be  used  for  any  length  of  time.  In  anemic  patients 
with  constipation  the  following  pills  are  of  service: 

I^.     Pill  (Blaud  iron) gr.  v  (0.324) 

Aloin gr.  3jV  (0.032).— M. 

One  pill. 
Sig. — One  to  two  pills  t.  i.  d.  after  meals. 

or 

I^.     Blaud' s  iron  pill gr.  X  (0.6) 

Pulv.  capsici gr.  i  (0.016) 

Aloini  1 

Strychnin  sulph.  >- aa  gr.  3^5-  (0.0022). — M. 

Acid  arseniosi       j 
One  pill. 
Sig. — One  pill  t.  i.  d.  after  meals. 

Fecal  Colic,  Fecal  Tumor. — It  is  an  error  to  at  once  administer 

large  doses  of  cathartics,  and  in  some  cases  positive  harm  may  result. 

The  rectum  should  first  be  examined  and  all  material  found  therein 

removed  by  the  finger  and  then  by  enemata.     High  injections  of 

soapsuds  and  water,  in  all,  1500  cc,  containing  olive  oil  .5  viij  (250  cc.) 

to  I  pint  (500  cc),  should  be  given,  in  some  cases  in  the  knee-elbow 

posture,  in  order  to  soften  and   remove  accumulation;     L'requent 

injections  and  irrigation^  should  be  given  to  start  movement  for  the 

first  twenty-four  to  forty-eight  hours.     Ox-gall,  oj  to  iij  (4.0-12.0), 

with  glycerin,  5ij  to  .^ss  (8.0-16.0),  added  to  the  enema  are  of  value. 

1  Compound  jalap  powder,  gr.  30  (2.0),  with  calomel,  gr.  v  (0.6),  is  a  good 
combination. 


472  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Olive  oil,  oij  to  vj  (60.0-200  cc),  can  be  given  by  mouth  if  neces- 
sary t.  i.  d-  to  soften  the  dejecta.  Later,  castor  oil,  calomel,  or  com- 
pound jalap  by  mouth,  and  saline  cathartics. 

Frequent  irrigations,  in  some  cases  with  electricity,  can  be  added 
to  the  treatment.  Large  doses  of  tincture  of  belladonna  and  strych- 
nin may  later  be  of  service.  In  some  cases  it  takes  several  weeks  for 
an  old  accumulation  to  be  completely  removed. 

Spasm  of  the  Sphincter. — This  should  alwa5^s  be  examined  for, 
especially  in  cases  of  spastic  constipation.  Gradual  dilatation  or 
rapid  dilatation  under  an  anesthetic  are  curative.  Local  disease 
should  be  treated. 

DIARRHEA 

Clinically,  diarrhea  may  be  defined  as  abnormal  rapidity  of  in- 
testinal peristalsis,  accompanied  by  frequent  evacuations  of  the  bowel 
contents,  which  are  too  liquid  or  are  watery  in  character. 

Some  patients  normally  pass  solid  dejecta  several  times  a  day, 
but  this  is  not  diarrhea;  yet  a  single  solid  movement  may  possess 
pathologic  significance. 

Diarrheal  stools  are  caused  by  the  excess  of  water  in  the  feces, 
and  may  be  due  to  the  liquid  contents  of  the  small  intestine  being 
so  rapidly  hurried  into  the  colon  that  little  absorption  is  able  to  occur 
in  the  small  intestine.  Free  transudation  of  water  from  the  blood- 
vessels or  the  glands  may  be  a  factor. 

Rapid  peristalsis  in  both  the  small  and  large  intestines,  or  in  the 
latter  alone,  is  another  cause. 

At  times  increased  peristalsis  is  the  only  factor,  and  there  are  no 
chemic  or  physical  changes  in  the  bowel  contents  and  no  structural 
changes  in  the  wall  of  the  gut.  Increased  peristalsis  usually  involves 
the  large  intestine  as  well  as  the  small. 

Pathologic  increase  of  intestinal  peristalsis  may  be  produced  in 
numerous  ways.  In  the  majorit}^  of  cases  it  is  caused  by  intestinal 
diseases  in  which  anatomic  changes  are  present,  as  in  intestinal 
catarrh,  ulcers,  typhoid,  etc.  It  may  be  present  without  any  ap- 
parent anatomic  lesions,  as  a  result  of  irritants  in  the  contents  of  the 
bowel;  or  when  the  contents  are  normal,  but  the  irritability  of  the 
nerves  of  the  intestinal  wall  is  increased ;  or  when  the  muscular  coats 
of  the  intestines  are  stimulated  by  an  irritant  circulating  in  the  blood 
or  affecting  the  central  nervous  system. 

Frequently  there  are  several  factors.  The  appearances  of  the 
evacuation,  both  macroscopic  and  microscopic,,  in  diarrhea  vary  ac- 
cording to  the  etiology  of  the  disease  and  the  anatomic  changes  in  the 
gut,  when  such  are  present. 

In  every  diarrhea  it  is  important  to  know  whether  it  is  produced 
by  abnormal  transudation  or  exudation,  with  increased  peristalsis 
of  the  large  intestine;  or  whether  in  addition  the  peristalsis  of  the 
small  intestine  is  increased.  In  the  last  event  large  quantities  of  un- 
changed digestive  fluids  and  undigested  food  remnants  are  evacu- 


CONSTIPATION    AND    DIARRHEA  473 

ated,  and  nutrition  is  markedly  impaired.     Bile-pigment  reaction 
in  the  feces  shows  involvement  of  the  small  intestine. 

We  may  classify  two  forms  of  diarrhea:  first,  with  intestinal 
lesions ;  second,  diarrhea  without  lesions.  The  first  group  is  described 
in  the  appropriate  sections.  The  second  group,  with  no  intestinal 
lesions,  is  classified  as  follows: 

1 .  Diarrhea  due  to  irritation  from  the  bowel  contents.  Diarrhea 
dyspeptica,  Diarrhea  gastrica,  Diarrhea  stercoralis,  and  Diarrhea  en- 
tozoica  are  subdivisions. 

2.  Diarrhea  due  to  irritants  transmitted  in  the  blood,  such  as  the 
uremic  type. 

3.  Diarrhea  nervosa  (nerv^ous  diarrhea),  due  to  irritation  of  the 
nervous  system. 

4.  Diarrhea  Cathartica. — This  type  belongs  in  a  class  ^  by  itself. 
The  majority  of  purgatives  stimulate  the  peristaltic  action  of  the 
entire  intestinal  tract.  The  peristaltic  action  of  the  large  intestine 
is  chiefly  affected,  as  by  the  aromatic  laxative  drugs.  The  move- 
ments in  this  case  are  thin  and  liquid,  since  increased  peristalsis 
interferes  with  the  absorption  of  the  ingesta  and  intestinal  secretions. 

With  the  alkaline  laxative  salts  the  action  is  not  only  to  increase 
peristalsis,  but  they  withdraw  the  water  from  the  blood  and  stimulate 
the  intestinal  secretions.  The  prolonged  use  of  drastic  purgatives 
or  excessively  large  doses  produce  an  acute  catarrh  of  the  intestines. 

Diarrhea  Due  to  Irritation  of  the  Bowel  Contents 

Diarrhea  Dyspeptica. — Certain  articles  of  diet  may  produce 
diarrheal  evacuations,  such  as  fresh  fruit,  cucumbers,  pickles,  cab- 
bage, turnips,  beets,  etc.  Patients  vary  as  to  suceptibility.  Milk 
produces  diarrhea  in  some,  while  others  it  constipates.  Excess 
of  food  or  too  great  ingestion  of  water  or  beer  with  the  food  may 
prevent  gastric  digestion.  The  ingesta  entering  the  intestines  un- 
changed may  cause  diarrhea. 

Intestinal  fermentation  or  putrefaction,  spoiled  food,  and  auto- 
intoxication may  produce  diarrhea.  With  the  last  the  diarrhea  is 
due  to  more  than  the  mere  local  irritation. 

In  neglected  or  severe  cases  of  pure  dyspeptic  diarrhea,  long-con- 
tinued irritation  may  give  rise  to  true  catarrh. 

Diarrhea  Gastrica. — Einhorn  and  Oppler  first  called  attention 
to  diarrhea  resulting  from  disturbances  of  the  stomach  functions. 

Hypochlorhydria  and  achylia  gastrica  are  the  most  frequent 
causes  of  this  type  of  diarrhea;  more  rarely  hyperchlorhydria  or 
motor  insufficiency.  In  hypochlorhydria  or  achylia,  diarrhea  with 
intestinal  symptoms  such  as  flatulence,  borborygmi,  and  colicky 
pains  may  predominate.     The  stools  are  often  quite  undigested. 

These  cases,  if  prolonged,  may  develop  intestinal  catarrh. 

1  This  type,  thus  referred  to  by  Nothnagel,  is  merely  mentioned  in  passing. 
Colocynth  and  aloin  in  excess  may  also  produce  the  condition. 


474  DISEASES    OF    THE    STOMACH    AND   IXTESTINES- 

Diarrhea  Stercoralis. — Diarrhea  with  constipation.  If  consti- 
pation occurs  in  a  person  whose  bowels  usually  are  regular,  diarrhea 
may  follow  the  attack  of  constipation.  The  diarrhea  is  accom- 
panied'by  coUcky  pains,  bloating,  and  by  the  development  of  more  or 
less  offensive  gases,  such  as  sulphuretted  hydrogen,  etc.  • 

It  is  beUeved  that  the  diarrhea  is  caused  by  the  development  of 
these  gases  in  the  intestinal  contents  as  a  result  of  stagnation  of  the 
fecal  matter.  Hardened  fecal  matter  may  irritate  the  mucosa  and 
produce  secretion  and  peristalsis.  With  stercoral  diarrhea  the  pas- 
sages are  at  first  formed,  then  mushy,  and  finally  liquid.  Scybalae 
may  be  found  in  the  dejecta. 

The  passage  of  flatus  affords  temporary  relief.  Thorough  evacua- 
tion of  the  bowels  relieves  all  the  symptoms.  Neglected  cases  may 
cause  intestinal  catarrh. 

Diarrhea  Entozoica. — Intestinal  parasites,  the  tapeworm,  for 
example,  may  in  some  cases  cause  persistent  diarrhea.  Like  other 
types  of  diarrhea,  there  are  probably  at  first  no  changes  in  the  mucosa, 
but  long-continued  irritation  will  produce  catarrh. 

Diarrhea  Due  to  Irritants  Transmitted  in  the  Blood 

Diarrhea  due  to  the  hypodermic  injection  of  certain  drugs  belongs 
to  this  class.  The  diarrheas  of  septicemia,  nephritis,  diabetes, 
cholera,  malaria,  etc.,  are  explainable  by  this  theory. 

Diarrhea  Nervosa  'Nervous  Diarrhea) 

This  type  depends  on  nen.-ous  disturbances,  without  any  morbid 
changes  in  the  walls  of  the  intestines.  Trousseau  first  described 
nervous  diarrhea.     No  impairment  of  digestive  functions  is  present. 

It  originates  either  from  excessive  stimulation  of  the  nerves 
governing  peristalsis  (the  motor  function)  or  from  the  transudation 
of  serous  material  into  the  intestinal  canal  (secretory  function), 
produced  by  ner^'ous  influences.  In  some  cases  probably  both 
factors  are  concerned. 

The  stimulus  may  arise  from  the  nen.-e  centers  and  be  transmitted 
through  the  fibers  of  the  vagus,  sympathetic,  or  splanchnic  ner\-es 
to  the  intestinal  ganglia. 

As  an  example  of  nervous  diarrhea,  numerous  watery  evacuations 
may  occur  as  the  result  of  some  emotion,  such  as  fright  or  shock, 
in  which  cases  the  stimulus  arises  in  the  brain  centers.  These  are 
more  especially  acute  transitory  attacks. 

Nothnagel  and  Peyer'  report  instances  of  chronic  ner^^ous  diarrhea: 
thus,  some  persons  will  be  attacked  with  gurgling,  abdominal  pain, 
tenesmus,  and  diarrhea  as  soon  as  they  find  they  can  secure  no  access 
to  a  water-closet ;  while  with  others  the  sight  of  the  toilet  produces 

1  Wiener  Klinik,  1893,  Heft  i. 


CONSTIPATION    AND    DIARRHEA  475 

diarrhea.  Some  patients  may  have  attacks  at  definite  hours,  without 
any  relation  to  surrounding  conditions. 

In  others,  nervous  symptonis  precede  the  diarrhea,  such  as  vertigo, 
stupor,  giddiness,  congestion  of  the  head,  reddening  of  the  face, 
hot  flushes  over  the  body,  fear,  oppression,  palpitation,  rapid  breath- 
ing, etc.  These  symptoms  often  disappear  after  a  few  diarrheal 
movements. 

The  number  of  stools  varies;  these  may  be  from  two  to  four, 
or  even  to  fifteen,  consisting  of  thin  liquid  contents,  with  mucus 
rarely  present.  At  times  the  first  movement  is  solid,  the  next 
mushy,  and  the  subsequent  movements  liquid. 

Occasionally  peristaltic  unrest,  borborygmi,  and  severe  tenesmus 
may  accompany  the  movements. 

This  form  of  diarrhea  is  found  as  a  symptom  in  hysteria  or 
neurasthenia,  in  the  nervous  and  debilitated,  and  even  in  healthy 
persons  after  a  nervous  shock. 

With  Graves'  disease  and  migraine  this  type  may  occasionally 
occur. 

Charcot^  describes  attacks  with  tab^s  (intestinal  crisis).  Peyer 
speaks  of  a  reflex  form  of  nervous  diarrhea  found  in  consequence  of 
abnormal  processes  in  the  genito-urinary  tract;  for  example,  in 
uterine  catarrh,  emissions,  spermatorrhea,  and  sexual  excess. 

Fischl  cites  a  case  of  diarrhea  which  persisted  for  several  years 
and  resisted  all  treatment.  Replacement  of  a  reflexed  uterus  cured 
the  case. 

Vicarious  diarrhea  in  pregnant  women  of  the  neuropathic  type 
has  been  described  by  Condio.  The  diarrhea  takes  the  place  of 
vomiting. 

Nervous  diarrhea  has  also  been  attributed  to  excessive  smoking. 

Diarrhea  from  Exposure  to  Cold  and  Wet 
This  occurs  after  a  sudden  or  severe  chill  from  exposure  to  cold, 

or  wetting  of  the  surface  of  the  body,  especially  the  feet  or  abdomen. 

Probably  it  is  due  to  reflex  irritation,  transmitted  from  the  cutaneous 

nerves. 

Accelerated  peristalsis  of  the  intestines  occurs,  whether  due  to 

reflex  stimulation  or  secondary  to  hyperemia,  it  is  uncertain.     This 

type  of  diarrhea  is  usually  transitory.     At  times  it  may  assume  the 

character  of  true  intestinal  catarrh. 

Treatment  of  Diarrhea 
The  method  of  treatment  depends  on  the  cause.  In  the  cases 
with  anatomic  lesions  in  the  intestines,  regulation  of  the  diet  and 
medication  appropriate  to  each  special  type  should  be  carried  out. 
These  methods  are  described  under  their  special  sections,  such  as 
under  Intestinal  Catarrh,  Dysentery,  etc. 

^  Prager  med.  Wochenschr.,  1891. 


476  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

With  diarrhea  due  to  a  laxative,  heat  to  the  abdomen  and  opium 
are  indicated.  Pilulae  opii,  gr.  j  (0.065),  three  or  four  times  a  day, 
or  one  of  the  other  opium  preparations,  or 


I^.     Tinct.  opii oiiss 

Bismuth,   subnit oiij 

Mist,  cretae q.  s.  oiv 

Sig. — Shake.     Two  teaspoonfuls  (8.0)  four  times  a  day. 


12 

125. — M. 


With  dyspeptic  and  stercoral  diarrheas  thorough  removal  of 
the  sources  of  irritation  are  indicated,  such  as  the  use  of  calomel  or 
blue  mass,  gr.  v  (0.3),  castor  oil,  oiss  (45.0),  or  a  saline  cathartic^ 
such  as  magnesium  sulphate,  oss  to  oj  (15-30  gm.),  or  Sprudel  salts, 
apenta,  etc.     Intestinal  irrigation  is  indicated  in  these  types. 

For  intestinal  parasites  an  appropriate  remedy  and  a  cathartic. 

For  Diarrhea  Gastrica. — Treatment  should  be  given  for  the 
existing  condition  in  the  stomach ;  for  hypochlorhydria,  stomachics, 
dilute  hydrochloric  acid,  intragastric  faradization,  etc. 

For  achylia  gastrica,  chiefly  vegetable  food,  finely  divided,  and 
the  methods  employed  for  this  condition. 

For  hyperchlorhydria,  a  rare  cause,  diet  and  the  alkalis,  etc.,  are 
indicated. 

For  Diarrhea  Due  to  Irritants  Transmitted  in  the  Blood. — 
The  cause  should  receive  treatment,  thus,  nephritis,  malaria,  etc. 
The  general  condition  should  be  improved. 

Heat  locally  to  the  abdomen,  liquid  diet,  rest  in  bed,  the  bismuth 
and  astringent  preparations,  such  as  bismuth  subnitrate,  gr.  30  (2.0) 
t.  i.  d.,  bismuth  salicylate,  gr.  10  (0.6)  t.  i.  d.,  or  bismuth  subgallate, 
gr.  10  (0.6)  four  times  a  day;  or  tannalbin,  tannigen,  tannopin,  or 
tanocol,  gr.  10  (0.6)  each,  three  or  four  times  a  day. 

Opium  preparations  may  be  required,  but  should  be  used  with 
caution. 

Nervous  Diarrhea. — -If  this  depends  on  reflex  action,  such  as 
from  uterine  disturbance,  etc.,  the  primary  affection  must  be  treated. 

In  other  cases  the  general  condition  of  the  patient  must  be  built 
up.  Neurasthenic  and  hysteric  conditions  must  receive  special 
treatment.     Constipating  food  may  be  administered. 

Iron  preparations,  such  as  iron  tropon,  oj  to  ij  (4.0-8.0),  t.  i.  d. ; 
peptomangan  (Gude),  oj  to  oss  (4.0-16.0),  in  water  t.  i.  d. ;  or  Fowler's 
solution  of  arsenic,  TTLv  (0.296  cc),  or  smaller  doses  t.  i.  d. ;  or  sodium 
arsenate,  gr.  -gV  to  2's  (0.0013-0.0026),  are  of  value  as  tonics. 

I^.     Blaud's  iron  pill gr.  v  (0.6) 

Sodium  arsenate gr.  -^V  (0.0013). — M. 

One  pill.     Make  30  such  pills  soft  with  honey  and  silver  coat. 
Sig. — One  t.  i.  d.  after  meals. 

The  bromids  of  sodium,  ammonium,  or  potassium,  or  bromid  of 
strontium,  given  for  a  few  weeks,  gr.  15  to  30  (1.0-2.0)  t.  i.  d.,  lessen 
irritability. 


CONSTIPATION    AND    DIARRHEA  477 

Bismuth  subnitrate  or  salicylate,  in  dosage  already  given,  silver 
nitrate,  gr.  i  to  |  (0.008-0.016),  and  the  astringents  noted  above 
are  useful.     Heat  should  be  applied. 

Opium  and  its  derivatives  are  generally  recommended  for  this, 
as  well  as  other  types  of  diarrhea,  and  are  preferable  to  morphin. 

The  general  tendency  to  at  once  prescribe  opiates  in  all  diarrheas 
is  to  be  deplored,  especially  in  the  nervous  type,  as  the  habit  is 
readily  gained.  If  other  remedies  fail,  they  may  be  used  with  caution. 
The  following  (Wm.  H.  Thomson)  is  a  useful  combination  for  such 
purposes.     The  dosage  is  small: 

^-     Pulv.  opii        )  aa  er   V  (o  ^) 

Silver  nitrate  J *  '      ^  '"^^ 

Resin  of  turpentine oij  (8.0) 

Liquor  potass 3  j  (4-o) 

Pulv.  licorice q.  s.  to  make  pills  soft. — M. 

Divide  in  pil.  No.  Ix. 
Sig. — Two  or  three  pills  t.  i.  d. 

I^.     Tinct.  opii  camphor  I  aa  ^ss  deo^ 

Bismuth  subnit.  J    aa  oss  (.ib.oj 

Mist,  cretae q.  s.  5iv  (125  cc). — M. 

Shake. 
Sig. — Two  teaspoonfuls  in  water  every  two  or  three  hours. 

I^.     Tinct.  opii 3iij  (12.0) 

Tinct.  catechu  comp oss  (16.0) 

Aq.  destil q.  s.  ad.    oiv    (125  cc). — M. 

Shake. 
Sig. — Two  teaspoonfuls  in  water  every  three  hours. 

Opium  pills  or  other  combinations  can  be  employed. 

In  nervous  diarrhea  the  intestines  should  be  trained  in  the  normal 
direction.  Suggestion  by  the  physician  is  of  value.  The  patient 
should  be  instructed  that  after  his  morning  evacuation  he  should 
refrain  from  other  movements  except  when  absolutely  necessary. 
Often  he  can  thus  control  the  desire. 


CHAPTER  XXIII 

INTESTINAL  CATARRH;  ENTERITIS;  COLITIS;  CATAR- 
RHAL SIGMOIDITIS;  PROCTITIS;  PHLEGMONOUS 
ENTERITIS 

ACUTE  AND  CHRONIC  INTESTINAL  CATARRH 

(Synonyms. — Enteritis;  Catarrhus  Intestinalis.) 

Intestinal  catarrh  is  one  of  the  commonest  conditions  with 
which  we  have  to  deal,  and  is  of  importance,  since  in  acute  cases  in 
the  young  or  aged  it  may  seriously  endanger  the  life  of  the  patient ; 
while  the  chronic  cases  are  often  obstinate  and  difficult  to  cure,  and 
may  impair  the  general  health. 

It  occurs  in  two  types,  the  acute  and  chronic,  and  these  in  turn 
may  be  primary  or  secondary  to  some  other  disease. 

ACUTE  INTESTINAL  CATARRH 

(Synonyms. — Enteritis  Acuta;  Catarrhus  Intestinalis  Acutus;  Cholera  Nostras; 

Acute  Diarrhea.) 

Acute  intestinal  catarrh  is  defined  as  an  acute  inflammation  of 
the  intestines,  characterized  by  pains  of  considerable  severity  and 
accompanied  by  diarrheal  movements  containing  an  admixture  of 
mucus.  The  disease  may  attack  a  portion  of  the  bowel  and  we  may 
have  a  duodenitis,  jejunitis,  ileitis,  colitis,  sigmoiditis,  and  proctitis. 
In  many  cases  the  entire  intestinal  tract  is  involved.  Appendicitis 
is  described  in  a  separate  chapter.  Though  Woodward^  held  that 
the  small  intestine  may  not  be  involved  alone,  yet  it  unquestionably 
occurs.  In  many  cases  acute  catarrh  of  the  colon,  on  the  other  hand, 
gives  the  prominent  symptoms,  though  there  is  frequently  involve- 
ment of  the  ileum.  The  inflammation  may  also  be  confined  to  the 
large  intestine. 

Etiology. — Age. — It  may  occur  at  all  ages,  and  is  frequently 
found  in  infants  and  children.  Acute  intestinal  catarrh  may  be  pri- 
mary (idiopathic)  or  secondary  to  some  other  disease. 

Primary  acute  catarrh  is  due  to  the  following  causes:  i.  An 
excessive  quantity  of  food,  so  that  a  considerable  portion  remains 
undigested  and  acts  as  a  source  of  irritation ;  heavy  and  indigestible 
food;  extremely  cold  drinks,  or  an  idios^'ncrasy  to  certain  foods. 
In  others,  who  are  suffering  from  slight  intestinal  disturbances, 
some  articles  of  diet  which  otherwise  would  produce  no  difficulty 
may  lead  to  the  development  of  catarrh.  Unripe  fruit,  tainted 
meat,  milk  or  fish,  or  vegetables  that  are  overripe  or  spoiled.  Auto- 
intoxication with  diarrhea  may  result  from  ingestion  of  such  ma- 
^  Medical  and  Surgical  History  of  the  War  of  the  Rebellion. 
478 


ACUTE  INTESTINAL  CATARRH  479 

terial,  and  catarrh  is  frequently  produced  if  the  source  of  irritation 
is  not  immediately  removed. 

2.  Chemic  irritants,  both  organic  and  inorganic  substances, 
such  as  colocynth,  croton  oil,  jalap,  senna,  podophyllin,  spices, 
pepper,  copaiba,  mustard,  garlic,  cantharides,  mercury,  arsenic, 
lead,  copper,  tartar  emetic,  phosphorus,  antimony,  alcohol,  chloro- 
form, ether,  and  some  of  the  alkaloids,  such  as  colchicin,  veratrin, 
acids,  and  alkalis.  With  concentrated  irritants  the  mucosa  may  be 
permanently  damaged.  Catarrh  is  caused  when  smaller  quantities 
are  ingested. 

3.  Mechanical  irritants,  such  as  hardened  scybalae,  enteroliths, 
biUary  calculi,  foreign  bodies,  such  as  seeds,  fruit  pits,  coins,  etc. 

4.  Exposure  to  cold  or  high  temperature,  especially  in  children 
and  infants,  or  sudden  variation  in  temperature,  wetting  the  feet, 
are  predisposing  causes;  these  conditions  probably  favoring  the 
development  of  micro-organisms  and  producing  circulatory  change. 

5.  Chemic  irritants  from  the  blood,  such  as  in  catarrhal  nephri- 
tis, catarrh  from  mercurial  inunction,  or  from  abdominal  burns. "^ 

Acute  intestinal  catarrh  may  be  secondary : 

1.  To  general  infection,  as  in  typhoid,  dysentery,  cholera,  sepsis, 
influenza,  pneumonia,  scarlatina,  measles,  malaria,  rheumatism, 
or  other  infectious  diseases. 

In  dysentery  and  typhoid  the  ulcerations  are  in  part  responsible. 

2.  Direct  action  of  micro-organisms,  as  in  infantile  catarrhs  due 
to  the  activity  of  numerous  types,  such  as  proteus  vulgaris  and 
streptococci.  Bacillus  enteritidis  sporogenes,-  colon  bacillus,  also 
Bacilli  dysenterii. 

3.  Extension  of  inflammatory  process  from  adjacent  parts,  as 
in  peritonitis,  invagination,  hernia,  tubercular  or  cancerous  ulcera- 
tion, and  thrombosis. 

4.  Diseases  of  the  liver,  heart,  and  lungs  due  to  stasis  and  engorge- 
ment. 

5.  In  cachexia  of  cancer,  profound  anemia,  diabetes,  Addison's 
and  Bright's  disease,  intestinal  catarrh  may  be  a  terminal  event. 

_  Morbid  Anatomy. — The  entire  gastro-intestinal  tract  may  be 
involved  or  only  portions  of  the  intestines  are  affected.  These 
differences  depend  on  the  extent  of  the  catarrhal  process  and  upon 
the  cause  and  intensity  of  the  inflammation.  The  anatomic  changes 
are  not  always  commensurate  with  the  severity  of  the  symptoms. 

The  mucous  membrane  of  the  intestines  is  reddened  uniformly 
or  in  spots,  from  light  red  to  dark  purple  in  color,  especially  marked 
around  the  follicles  and  plaques,  on  the  summit  of  the  valvulae 
conniventes  and  of  the  villi.     If  the  inflammatory  process  is  intense, 

1  Elimination  of  the  poisons  through  the  bile  and  from  the  blood  during  intes- 
tinal secretion  is  the  probable  cause  of  the  catarrh. 

2  This  was  believed  to  be  possibly  an  impure  culture  of  the  Bacillus  aerogenes 
capsulatus,  though  possibly  it  is  a  distinct  organism  (Herter,  Bacterial  Infections 
of  the  Digestive  Tract) . 


480  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

extravasations  of  blood  occur.  The  mucous  membrane  is  swollen 
and  edematous,  and  is  often  covered  with  tenacious  glassy  mucus, 
stained  by  bile  or  blood  and  more  or  less  opaque.  Desquamated 
epithelial  cells  and  occasionally  a  few  pus-cells  are  seen  in  the  mucus 
under  the  microscope ;  layers  of  epithelium  may  desquamate  and  form 
gray  shreds.  Fecal  contents  are  usually  liquid.  The  villi  and  soli- 
tary follicles  are  swollen  and  appear  as  whitish  nodules  surrounded 
by  a  red  injected  area  (enteritis  folHcularis  sen  nodularis). 

If  the  process  continues,  these  nodules  may  rupture  and  give  rise 
to  follicular  ulcers.  Catarrhal  ulcers  are  produced  by  loss  of  the 
epithelial  covering  and  extension  of  the  inflammation.  Irritation 
in  the  neighborhood  of  these  ulcers  may  in  protracted  cases  give 
rise  to  polypoid  growths. 

Microscopically,  there  are  congestion  and  distention  of  the  blood- 
vessels of  the  mucosa  and  submucosa  and  small  extravasations  are 
at  times  seen  between  the  glands  of  Lieberkiihn.  The  spaces  between 
the  glands  are  frequently  widened  and  contain  abundant  masses  of 
round  cells.  They  are  also  present  in  the  superficial  or  deeper 
layers  of  the  submucosa. 

The  swelling  of  the  solitary  follicles  is  due  to  proliferation  of 
their  cells  and  to  round-cell  infiltration.  This  is  also  true  of  Peyer's 
patches  when  they  are  involved,  which  is  rare  to  any  extent.  The 
epithelium  of  the  mucosa  is  detached,  especially  in  the  large  intestine, 
but  this  is  believed  to  be  chiefly  a  post-mortem  change. 

The  epithelium  is  undoubtedly  involved  in  the  catarrhal  process, 
as  degenerated  epitheHal  cefls  are  found  in  the  mucus  with  the  stool. 

The  cells  of  the  glands  may  be  cloudy  and  swollen. 

Crypts  of  Lieberkuhn. — The  glands  are  enlarged  or  the  fundus 
is  wider  than  normal,  the  opening  is  narrow,  so  that  the  crypt 
becomes  bottle  shaped.  They  may  be  detached  from  their  base 
and  raised,  or  protrude  into  the  intestines,  or  even  desquamate. 

The  submucosa  is  hyperemic.  The  muscular  and  serous  coats 
are  unaffected. 

Symptoms. — They  depend  on  the  etiology,  the  location  of  the 
catarrh,  and  its  severity,  so  that  considerable  variation  occurs.  The 
general  symptoms  of  an  ordinary  primary  attack  are  as  follows: 

It  usually  begins  with  a  feeHng  of  fulness  in  the  lower  part  of  the 
abdomen,  with  attacks  of  colicky  pains  and  diarrhea.  Nausea  and 
vomiting  may  be  associated  with  these  symptoms  at  the  incipiency 
of  the  attack.  In  the  mild  cases  there  may  be  no  temperature,  or 
it  may  be  moderate,  while  in  the  severe  types  there  may  be  a  chill 
with  rise  of  temperature  to  103°  to  104°  F.  In  some  cases  there 
may  be  tympanites.  There  are  gurgling  sounds  (borborygmi) 
and  the  abdomen  is  tender  on  pressure,  at  times  over  special  regions 
markedly  so.     Loss  of  appetite  occurs. 

The  number  of  stools  depends  upon  the  severity  of  the  case. 
There  may  be  only  two  or  three  movements  in  twenty-four  hours. 


ACUTE  INTESTINAL  CATARRH  48 1 

or  as  many  as  fifteen  to  tv>renty  evacuations.  The  first  one  or  two 
movements  usually  contain  fecal  matter  and  are  somewhat  mushy 
in  character.  They  rapidly  become  semifluid,  and  finally  thin  and 
liquid.  Feces  and  scybalae  may  be  found  "  later.  The  more  the 
colon  is  involved,  the  greater  is  the  diarrhea.  Diarrhea  does  not 
always  occur  if  the  small  intestine  alone  is  the  seat  of  inflam- 
mation. The  early  stools  are  frequently  of  a  dark  brown  color 
sometimes  of  offensive  odor,  the  latter  condition  being  especially 
noticeable  if  dietetic  errors  are  the  cause. 

The  amount  of  material  passed  exceeds  the  quantity  of  food 
ingested,  due  to  the  digestive  secretions  and  catarrhal  secretion,  all 
of  which  are  rapidly  evacuated.  When  the  stools  consist  of  watery 
discharge  and  mucus  there  is  often  little  or  no  odor.  They  are 
slightly  acid  in  reaction  and  foam-like  in  appearance. 

The  stools  may  be  light  yellow  in  color,  grayish,  or  even  greenish 
in  young  children,  or  colorless,  resembling  rice-water.  These  differ- 
ences in  color  are  dependent  upon  the  location  of  the  catarrh.  In 
the  yellow  fecal  material  Gmelin's  reaction  for  bile-pigment  can 
often  be  obtained,  and  this  is  also  found  in  the  green  movements, 
demonstrating  involvement  of  the  small  intestine.  The  colorless 
stools  most  frequently  occur  in  the  specific  choleraic  types. 

Mucus  is  contained  in  the  stools.  It  may  float  on  top  of  the 
dejections  in  shreds  of  various  sizes  and  be  of  glassy  appearance,  or 
be  stained  in  various  colors,  or  mixed  with  the  bowel  contents  and 
form  a  jelly-like  mass;  it  may  coat  the  feces  or  be  mixed  with  it  in 
small  amounts;  or  the  movement  may  consist  chiefly  of  mucus. 
In  some  cases  the  mucus  may  only  be  determined  by  the  microscope. 

The  localization  of  the  seat  of  the  catarrh  is  shown  by  the  charac- 
teristics of  the  mucus,  to  be  described  later. 

Microscopically,  there  are  epithelial  cells,  numerous  micro-organ- 
isms, mucus,  occasionally  a  little  pus  and  blood,  and  undigested  food 
particles.  Blood  is  found  only  in  severe  cases  where  there  is  marked 
congestion  or  ulceration,  and  pus  when  ulceration  is  present. 

Chemically,  peptones  and  sugar  may  be  present  in  the  dejecta. 

Macroscopically,  food  remnants  may  be  seen  with  the  naked  eye 
for  several  days,  especially  if  dietetic  indiscretion  be  a  factor. 

Subjective  Symptoms. — In  the  milder  cases,  except  for  the  colicky 
pains,  diarrhea,  and  the  feeling  of  pressure  and  fulness,  the  patients 
may  not  feel  very  badly.  In  more  severe  cases  they  may  feel  chilly, 
feverish,  dizzy,  and  weak,  at  times  nauseated,  and  in  some  cases 
thev  may  vomit.  Tenesmus  may  be  present  if  the  lower  part  of  the 
colon  or  rectum  are  affected.  Gas  may  be  expelled.  Borborygmi 
may  be  audible.  With  children  and  elderly  persons  the  symptoms 
are  often  pronounced.  Collapse  may  occur.  With  infants  the  hydren- 
cephaloid  condition  may  occur,  temperature  104°  F.  or  more,  sunken 
fontanels,  rapid  pulse,  cold  extremities,  collapse,  etc. 

General  Physical  Signs. — The  abdomen  may  be  bloated,  but 

31 


482  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

when  gas  is  expelled  the  distention  lessens  or  disappears.  Splashing 
sounds  can  often  be  elicited.  Over  the  abdomen  usually  there  is  ten- 
derness on  palpation,  especially  in  the  region  of  the  navel,  and  fre- 
quently in  the  right  or  left  iliac  regions,  or  along  the  course  of  the 
transverse  colon;  gurgling  sounds  can  often  be  heard  on  palpation. 
In  thin  subjects  peristaltic  movements  of  the  small  intestine  may  be 
visible  either  before  or  after  palpation. 

If  there  is  much  gas,  there  is  a  tympanitic  note  on  percussion; 
it  may  be  dull  in  character  if  much  fluid  be  present.  Large  accumu- 
lations of  gas  are  not  frequent. 

Fever. — There  may  be  no  temperature  or  only  moderate  fever. 
In  severe  types  the  temperature  may  be  quite  high  (102  °  to  104°  F.). 
In  some  cases  there  are  chills  associated  with  the  fever,  but  the 
temperature  has  a  tendency  to  fall  after  a  few  days  and  does  not  show 
the  characteristic  steady  increase  of  typhoid  fever.  With  tainted  food 
or  bacterial  infection,  fever  is  especially  apt  to  occur.  Such  cases 
run  an  acute  course  with  severe  clinical  symptoms.  Undoubtedly 
auto-intoxication  is  a  prominent  factor  in  their  production. 

With  gastroduodenitis,  jaundice  is  present,  and  often  vomiting. 

Urine  may  become  scanty  and  concentrated,  especially  in  severe 
cases  when  there  are  frequent  movements,  and  there  may  be  found 
cylindroids,  albumin  in  small  amounts,  and  hyaline  casts.  Indican 
is  often  present,  especially  if  the  small  intestine  is  involved. 

Rosenbach's  reaction  (Burgundy  red),  on  boiling  urine  with 
nitric  acid,  is  also  found.  This  also  shows  intestinal  putrefaction. 
Acetone  has  been  found. 

Localization  of  Acute  Catarrh. — Involvement  of  the  small  intes- 
tine alone  is  more  uncommon,  and  usually  associated  with  gastritis. 

I  believe  in  actite  cases  the  involvement  of  the  intestines  is  the 
more  frequent  occurrence,  though  the  intensity  of  inflammation  may 
be  greater  in  one  portion,  especially  in  the  colon.  Some  believe  the 
large  intestine  alone  is  most  frequently  involved.  This  is  more  so  in 
chronic  cases.     In  the  rectum  local  involvement  is  quite  frequent. 

Acute  catarrh  of  the  caput  coli,  due  to  fecal  accumulation,  at 
times  occurs,  and  this  must  be  difi'erentiated  from  appendicitis. 
The  fecal  tumor  can  be  generally  discovered  by  the  doughy  feel  on 
palpation.  The  acute  symptoms  subside  rapidly  under  intestinal 
irrigation  and  catharsis. 

This  refers  to  a  simple  catarrh  and  not  to  a  true  typhlitis  which 
involves  the  muscular  tissue.  Acute  catarrh  ma)'-  occur  in  the 
sigmoid  and  should  be  classified  as  catarrhal  sigmoiditis.  In  sig- 
moiditis or  perisigmoiditis  the  musculature  is  also  involved.  The 
cases  described  by  Mayor  and  Leube  are  evidently  of  this  type. 
Diverticulitis  belongs  to  this  last  class.  The  nomenclature  should 
be  very  specific. 

Localized  Physical  Signs. — An  acute  duodenitis  is  usually  asso- 
ciated with  acute  gastritis,  and  we  have  jaundice  with  local  tender- 


ACUTE  INTESTINAL  CATARRH  483 

ness  on  pressure  in  the  right  portion  of  the  epigastric  region.  Inflam- 
mation of  the  duodenum  with  local  tenderness  may  occur  after  cuta- 
neous burns. 

Tenderness  on  pressure  (pain),  confined  to  the  middle  of  the 
abdomen  and  not  laterally,  shows  the  affection  to  be  probably 
confined  to  the  other  portions  of  the  small  intestine ;  but  when  the 
small  intestine  alone  is  involved,  as  diarrhea  is  usually  absent,  the 
diagnosis  is  difficult.  The  presence  of  a  considerable  number  of 
undigested  food  particles  and  epithelial  cells  tinged  with  yellow  bile- 
pigment  in  the  feces;  microscopic  mucus  mixed  with  the  stool,  with 
rarely  a  small  amount  of  visible  mucus,  are  a  valuable  aid  to  the 
diagnosis.     Indican  is  usually  present  in  the  urine. 

Acute  Colitis. — With  acute  colitis^  the  pain  and  tenderness  are 
most  marked  along  the  course  of  the  colon,  over  the  cecum,  trans- 
verse or  descending  colon,  sigmoid  flexure,  or  over  all  together.  The 
stools  are  diarrheal  and  contain  considerable  mucus. 

Proctitis  is  characterized  by  tenesmus  and  colicky  pains  in  the 
left  iliac  fossa.  There  is  a  constant  desire  to  defecate.  The  scybalae 
or  stools  are  surrounded  with  mucus,  sometimes  tinged  with  blood, 
and  the  mucous  membrane  may  prolapse  during  defecation  and  is 
red  and  tender.  Rectal  digital  examination  is  accompanied  by  much 
pain,  and  the  examining  finger  shows,  at  times,  traces  of  blood. 

The  most  important  method  of  diagnosis  to  localize  the  process 
is  by  examination  of  the  feces,  noting  the  character  of  the  mucus. 
Macroscopic  examination  is  often  sufficient. 

When  pure  mucus  is  passed  without  any  fecal  admixture,  catarrh 
of  the  rectum,  sigmoid,  or  of  the  descending  colon  is  indicated. 

If  small  masses  of  fecal  matter  or  solid  balls  are  passed  covered 
with  a  layer  of  mucus,  the  same  condition  is  indicated. 

If  there  is  catarrh  of  the  entire  large  intestine  up  to  the  cecum, 
even  if  the  movements  are  thin,  shreds  of  mucus  are  intimately 
mixed  w'ith  the  fecal  matter,  and  can  be  recognized  by  the  naked  eye. 

The  close  admixture  of  fecal  material  and  mucus  distinguish  it 
from  catarrh  of  the  lower  colon. 

In  catarrh  of  the  upper  colon  alone  or  of  the  small  intestine,  or 
small  intestine  and  upper  colon  alone,  usually  no  mucus  can  be  seen 
with  the  naked  eye,  and  hyaline  microscopic  lumps  of  mucus  are 
found  intimately  mixed  with  the  stools.  Small  amounts  mixed 
in  the  feces  are  at  times  visible. 

Diagnosis. — If  a  colon-tube  be  introduced  high  into  the  rectum, 
and  lavage  be  carried  out  intermittently  with  warm  water  through  a 
funnel,  by  the  same  method  as  lavage  of  the  stomach,  the  recovered 
fluid  will  contain  visible  mucus,  and  demonstrate  that  catarrh  of  the 
large  intestine  is  present.     This  method  was  suggested  by  Boas. 

The  presence  of  yellow  mucoiis  granules  in  the  movements  have 

1  More  properly,  acute  catarrhal  colitis,  to  distinguish  it  from  dysenteric  and 
other  types. 


484  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

been  considered  diagnostic  of  inflammation  in  the  small  intestine, 
though  Schmidt  and  Boas  believe  them  to  be  structureless  remains  of 
muscle  substance,  casein,  or  egg-albumen,  colored  with  bile-pigment. 

Bile-pigment. — If  bile-pigment  reaction  can  be  obtained  in  the 
stool  or  in  some  of  its  constituents,  this  indicates  an  inflammation 
of  the  small  intestine,  and  the  more  marked  the  reaction,  the  higher 
up  the  involvement.  It  may  be  found  in  the  mucus,  and  this  may  be 
stained  a  dark  orange,  green,  or  greenish  yellow. 

Cylindric  epithelium,  round  cells,  or  rarely  fat  (droplets)  may  be 
stained  yellow. 

An  acid  reaction  of  the  stool  also  shows  involvement  of  the  small 
intestine. 

Boas  has  subjected  a  filtrate  of  the  feces  to  the  digestion  test  with 
a  small  piece  of  albumin,  and  when  the  result  is  positive,  justly  con- 
cludes that  the  condition  originates  in  the  small  intestine. 

Duration. — Mild  cases  may  rapidly  recover  in  three  to  five  days, 
while  severe  cases  often  continue  for  several  weeks.  The  intestine 
remains  susceptible  to  irritation  for  a  considerable  time,  and  errors 
in  diet  may  cause  a  recurrence  of  the  attack.  The  condition  may 
become  chronic.  Constipation  may  follow  the  acute  attack,  and  this 
should  carefully  be  treated,  lest  habitual  constipation  develop.  The 
acute  attack  may  never  be  entirely  recovered  from,  but  gradually 
develop  into  a  chronic  catarrh. 

Prognosis. — These  cases  frequently  recover  within  a  short  time, 
but  in  children  or  very  old  and  enfeebled  persons  the  disease  may 
occasionally  prove  fatal.  The  prognosis  as  to  cure  depends  upon  the 
etiology  of  the  disease ;  thus,  if  due  to  chemic  irritants,  the  condition 
may  become  chronic. 

Treatment. — Prophylaxis. — Particular  articles  of  food  or  drink 
known  to  produce  attacks  of  acute  intestinal  catarrh  should  always 
be  avoided.  Some  are  affected  by  ice-cream  and  ice-cold  drinks,  and 
these  should  be  forbidden.  Exposure  to  cold  or  wet  should  be 
avoided.     Rest  in  bed  should  he  enjoined. 

When  tainted  food  has  been  ingested  or  indigestible  or  an  excessive 
amount  of  food,  even  though  there  is  diarrhea,  a  laxative  should  be 
given  immediately  to  thoroughly  empty  the  bowel. 

Calomel,  gr.  5  to  10  (0.3-0.6),  followed  by  a  saline  cathartic, 
preferably  within  six  hours  for  rapid  effect,  or  castor  oil,  o]  to  ij 
(30.0-60.0),  should  be  given  to  an  adult.  Castor  oil  may  be  ad- 
ministered in  coft'ee,  sarsaparilla,  ginger  ale,  or  with  orange  or  lemon 
juice. 

For  infants  and  young  children  calomel,  gr.  ss  to  j  (0.32-0.65), 
in  divided  doses,  or  5  j  to  iss  (4.0-6.0)  of  castor  oil. 

If  an  acid  chemic  irritant  has  been  taken,  then  an  alkali  should 
be  given,  and  vice  versa.  Antidotes  should  be  administered  in  the 
case  of  chemic  poison.  It  is  preferable  also  to  administer  a  cathartic, 
so  as  to  remove  the  poison  from  the  intestinal  canal. 


acute;  intestinal  catarrh  485 

Knteroclysis  with  normal  saline  solution  at  110°  to  115°  F.  is 
indicated  in  all  these  cases,  employing  i  gallon  (4  liters)  by  the 
recurrent  method,  so  as  to  thoroughly  cleanse  the  large  intestine. 

Calomel  is  useful  when  there  are  flatulence  and  indicanuria. 
I  prefer  a  fairly  large  initial  dose  in  these  cases,  and  to  repeat  it  within 
a  few  days,  to  the  method  of  daily  small  doses.  There  is  some  danger 
of  salivation  from  frequent  small  doses.  Colonic  irrigation  once  or 
twice  a  day  is  of  great  importance. 

These  methods,  combined  with  salol  or  beta-naphtol-bismuth 
(orphol),  gr.  5  (0.3),  three  or  four  times  a  day,  with  the  other  bismuth 
preparations,  or  with  urotropin,  gr.  5  (0.3),  and  sodium  benzoate,  gr. 
10  (0.6),  are  generally  sufficient. 

Dilute  hydrochloric  acid  in  HXx  (0.59)  doses  t.  i.  d.  is  an  excellent 
adjunct,  providing  there  be  no  nausea  or  vomiting,  and  resorcin,  gr.  5 
(0.3)  t.  i.  d.,  may  be  employed  for  intestinal  fermentation.  One  of 
the  best  remedies  for  diarrhea  is  bismuth. 

Bismuth  subnitrate,  gr.  20  to  30  to  40  (1.3-2.0-2.6),  given  four 
or  five  times  a  day  is  of  service.  It  may  be  combined  with  sac- 
charated  pepsin  as  a  vehicle  in  mild  cases  in  smaller  doses. 

Bismuth  subnitrate,  saccharated  pepsin,  equal  parts,  ^  to  ^  tea- 
spoonful  every  two  or  three  to  four  hours  during  the  twenty-four 
hours. 

Bismuth  subcarbonate,  gr.  15  to  30  (1.0-2.0),  four  times  a  day. 

Bismuth  subgallate,  gr.  5  (0.3),  three  or  four  times  daily  with  the 
bismuth  subnitrate  is  excellent. 

Bismuth  salicylate,  gr.  5  (0.3),  four  times  a  day  is  a  good  anti- 
fermentative;  or  ichthoform,  gr.  5  (0.3)  t.  i.  d.,  in  combination  with 
bismuth  subnitrate.     Ichthalbin,  gr.  5  (0.3)  t.  i.  d.,  is  useful. 

Tannalbin,  tannigen,  or  tannopin,  gr.  5  to  10  (0.3-0.6),  can  be 
used  in  combination  with  bismuth. 

I^.     Bismuth,  subnit oss  (16.0) 

Mist,  cretse q.  s.  oiv  (125.0). — M. 

Sig. — Shake.  One  to  two  teaspoonfuls  in  water  every  two  or  three  hours. 
The  same  prescription  with  10  to  15  drops  (0.6-1.0)  of  tincture  opii  camphor  is 
useful  if  the  diarrhea  continues  excessive. 

The  following  represent  single  doses  of  remedies  which  can  be 
taken  every  three  or  four  hours  in  persistent  diarrhea : 

I^.     Tinct.  opii IfTtx  (0.59) 

Tinct.  kino  "1  ""   ITl         ('       8^ 

Comp.  tinct.  catechu  ) ^       ^  "     ^ 

Aqua  destil q.  s.  oij  (8.0). — M.      . 

I^.     Tinct.  opii. TlXx  (0.59) 

Mist,  cretae 5j  (40) 

Comp.  tinct.  catechu q.  s.  5ij  (8.0). — M. 

I^.     Bismuth,   subnit gr.  x  (0.6) 

Tinct.  opii  deodor HXx  (0.59) 

Aq.  cinnamomi q.  s.  oj  (4-o). — M. 


486  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

I  prefer,  however,  to  avoid  opiates  as  much  as  possible  in  my 
treatment. 

Cotoin,  0.06  to  0.1  (gr.  i  to  2) ;  tincture  coto,  TTLxv  (0.888),  or 
paracotoin,  in  double  dose  as  compared  to  the  cotoin,  have  been 
suggested  for  diarrhea. 

Codein,  gr.  i  to  ^  (0.008-0.016),  or,  rarely,  morphin  may  be  re- 
quired.    Patient  should  be  kept  in  bed. 

Dry  or  moist  heat,  or  Priessnitz  compress,  hot-water  bag,  flaxseed, 
or  milk  or  potato  poultice,  hot  pieplate,  hot  salt-bag,  compress  of  hot 
water,  pepper  poultice,  weak  mustard  and  flour  poultice  should  be 
applied.  If  symptoms  of  collapse,  warmth,  hot  drinks.  Camphor 
hypodermics  and  strychnin  are  indicated.  Hypodermoclysis  may 
be  required. 

Enteroclysis  is  useful  to  rid  the  bowel  of  irritating  material,  and 
for  treatment  of  the  acute  catarrh  when  located  in  the  colon.  It 
may  be  given  by  enema  ^  or,  preferably,  with  the  recurrent  tube. 

When  there  is  marked  fermentation — 

Acetozone i :  2000  to  i :  1000 

Alphazone 1 :  2cxdo  to  i :  locx) 

Peroxid  of  hydrogen 5  j  (32.0)  to  2  quarts  (liters),  or 

Salicylic  acid  (i :  1000) 2  quarts  (liters) 

Boracic  acid 3  j  (4-o)  to  2  quarts  (liters) 

Permanganate  of  potash i :  3000. 

Irrigate  with  2  or  3  quarts  (liters)  with  a  recurrent  tube  once  a  day. 

Soothing  irrigations  are  flaxseed  tea,  gum-arabic  solution  in 
water  at  110°  F.,  slippery-elm  water,  or  normal  saline  solution. 

Occasionally  astringent  irrigations  may  be  necessary. 

First  wash  the  bowel  with  warm  water,  then  inject  tannic  acid, 
gr.  30  (2.0)  to  I  Hter  (quart),  and  15  drops  (0.888)  of  laudanum,  and 
hold  a  while.  Weak  nitrate  of  silver,  gr.  5  (0.3)  to  i  quart  (hter), 
has  also  been  recommended,  but  is  better  in  chronic  cases.  Gas- 
tritis, jaundice,  and  malaria  should  be  treated,  if  present,  or  any 
disease  to  which  the  intestinal  catarrh  is  secondary. 

Diet. — Cold  drinks  should  be  avoided.     Sanatogen  is  useful. 

Warm  teas,  such  as  chamomile,  fennel,  anise  seed,  or  plain  tea 
and  gruels  (barley  or  rice),  with  or  without  milk,  very  dilute  milk 
with  lime-water,  etc.,  should  be  given.  Milk  is  often  indigestible  and 
barley  broths  preferable. 

Later,  bouillon,  water  soup  (bread  softened  in  hot  water  with 
butter  and  salt),  yelk  of  &gg  or  white,  or  entire  egg  (raw  or  soft 
boiled),  stale  bread,  boiled  water,  etc.     Avoid  carbonated  waters. 

As  soon  as  the  diarrhea  is  over,  soft-boiled  eggs,  calves'  brains, 

scraped  beef,  mashed  potatoes,  cocoa,  weak  coffee,  chicken,  chops, 

steak,  stale  bread  and  butter,  potatoes  mashed  or   baked  can  be 

given.     Fruit,  green  vegetables,  hot  breads,  fat,  and  acids  should 

be  avoided  for  a  considerable  period. 

1  About  I  to  i\  quarts  (1000-1500  cc.)  should  be  used  by  enema;  hips 
elevated,  injecting  with  a  long  tube. 


CHROiNIC    CATARRH    OF    THE    INTESTINES  487 

CHRONIC  CATARRH  OF  THE  INTESTINES;  CHRONIC  COLITIS 

{Synonyms. — Enteritis  Chronica;  Chronic  EnterocoHtis.) 

This  disease  is  characterized  by  a  chronic  inflammation  of  the 
mucous  membrane  of  the  intestines,  which  gives  rise  to  various 
functional  disturbances  of  the  bowels.     iVny  portion  may  be  affected. 

Etiology. — Chronic  intestinal  catarrh  may  arise  from  an  acute 
enteritis  which  shows  no  tendency  to  recovery,  or  more  frequently 
from  repeated  attacks  of  acute  catarrh  which  follow  each  other  at 
short  intervals  before  complete  recovery  occurs.  Patients  frequently 
pay  no  attention  to  an  apparently  mild  attack  and  disregard  the  rules 
of  diet  prescribed.     As  a  result,  the  condition  becomes  chronic. 

In  other  cases,  however,  chronic  catarrh  may  have  an  insidious 
onset  from  the  beginning.  Fecal  accumulation,  notably  scybalae, 
may  be  a  cause  of  a  subacute  or  chronic  catarrh.  Pressure  of  tumors 
narrowing  the  canal,  as  pressure  from  fibroids  of  the  uterus,  or  adhe- 
sions, may  be  factors. 

The  direct  causes  of  chronic  enteritis  are  the  same  as  in  the  acute 
type,  and  chronic  catarrh  may  be  either  primary  (idiopathic)  or 
secondary  to  other  affections.  For  the  complete  etiology  the  reader 
should  refer  to  the  causes  of  acute  intestinal  catarrh. 

Chronic  catarrh  may  be  secondary  to  diseases  of  the  lungs,  espe- 
cially tuberculosis,  and  also  diseases  of  the  liver,  heart,  kidneys,  and 
diabetes.  Intestinal  parasites,  tapeworms,  round-worms,  seat- 
worms, etc.,  may  be  causes  by  producing  irritation.  I  recently  at- 
tended a  case  of  splanchnoptosis,  in  which  there  was  marked  prolapse 
of  the  sigmoid  flexure  with  a  tendency  to  fecal  accumulation  therein. 
The  patient  never  had  an  acute  enteritis,  but  for  five  years  has  had 
discomfort  in  this  region,  and  invariably  every  few  days  the  passage 
of  strings  of  mucus  and  scybalae.  There  were  no  symptoms  of  mucous 
colic.  The  case  was  one  of  chronic  catarrh  of  the  sigmoid.  The 
symptoms  disappeared  under  treatment  for  visceroptosis.  The 
possibility  of  chronic  locaHzed  catarrh  from  visceroptosis,  associated 
with  fecal  accumulation,  is  worthy  of  consideration.  Chronic  ap- 
pendicitis is  suggested  as  a  cause  by  G.  R.  Lockwood,  and  the  cure  of 
chronic  colitis  has  followed  appendectomy. 

The  rectum  should  always  be  examined.  Pressure  on  the  rectum 
from  a  uterine  fibroid  I  have  seen  produce  partial  stenosis  with 
coprostasis  above  and  resulting  intestinal  catarrh.  Ulcer,  fissure, 
or  hemorrhoids  may  cause  not  only  local  manifestations,  but  catarrh 
higher  up.  I  have  seen  a  case  with  chief  symptoms  pointing  to 
the  descending  colon  and  sigmoid,  in  which  an  ulcer  high  in  the 
rectum  was  the  cause. 

Morbid  Anatomy. — The  anatomic  changes  in  chronic  enteritis 
are  similar  to  those  in  acute  cases,  being  characterized  by  hyperemia, 
swelling  of  the  mucous  membrane,  and  increased  secretion  of  mucus. 
The  color  of  the  mucosa  varies  from  a  dark  venous  red  to  a  pale  gray- 


488  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

ish-red  tint ;  in  some  cases  it  may  even  be  gray  or  slate  colored  from 
extravasation  of  pigment  between  the  glands  and  at  the  tips  of  the 
villi.     The  last  cases  are  those  of  long  duration. 

The  surface  of  the  mucous  membrane  is  covered  with  a  trans- 
parent viscid  mucus  and  the  epithehal  cells  are  cloudy,  in  a  condition 
of  fatty  degeneration,  and  partly  desquamated.  In  the  majority  of 
cases  of  chronic  catarrh  the  accumulations  of  round  cells  (which  are 
characteristic  of  the  acute  type)  are  not  seen,  but  there  is  connective- 
tissue  proliferation  in  the  chronic  form. 

Exceptions. — In  some  of  the  early  cases  of  chronic  enteritis  the 
microscopic  picture  may  be  much  the  same  as  in  the  acute  process; 
and  in  other  mild  cases  the  only  abnormality  determined  is  the 
accumulation  of  pigment  between  the  glands  or  in  the  muscularis 
mucosae  and  a  slight  widening  of  the  interstices. 

As  a  result  of  chronic  enteritis,  hypertrophy  or  atrophy  of  the 
intestinal  mucosa  may  develop. 

Hypertrophy  of  the  Intestinal  Mucosa. — The  glands  of  the  mucosa 
are  elongated,  tortuous,  irregular  in  shape,  and  may  form  diverticula. 
Their  orifices  may  become  occluded  through  connective-tissue 
proliferation  and  there  will  be  a  retention  of  secretion  and  the 
formation  of  cysts  (enteritis  chronica  cystica).  Connective-tissue 
proliferation  leads  to  the  formation  of  polypi  (enteritis  polyposa), 
which  are  more  rare,  and  are  usually  found  in  the  large  intestine. 
In  many  cases  the  walls  of  the  intestines  may  become  thickened 
throughout,  including  the  muscular  coat,  to  the  extent  of  several 
times  its  normal  thickness. 

Woodward  reports  a  few  cases  of  proHferation  of  the  intestinal 
mucosa  with  its  glands. 

Atrophy  of  the  Intestinal  Mucosa. — ^The  clinical  entity  of  atrophy 
of  the  intestines  has  been  in  considerable  dispute,  and  undoubtedly 
a  pseudo-atrophy  due  to  post-mortem  change  occurs. 

Riegel,  Bwald,  and  Einhorn  believe  there  is  a  true  intestinal 
atrophy.  In  view  of  the  existence  of  an  atrophy  of  the  gastric  mucosa 
resulting  from  a  chronic  gastritis  and  from  its  occurrence  in  pernicious 
anemia,  I  am  convinced  that  an  atrophy  of  the  intestinal  mucosa  may 
occur  in  advanced  cases  of  chronic  intestinal  catarrh.  The  condition 
I  believe  to  be  rare.  Such  atrophy  may  originate  in  the  glandular 
tissue  in  the  glands  of  Lieberkiihn.  There  may  be  an  infiltration  of 
round  cells,  a  fatty  degeneration,  a  disintegration,  and  desquamation 
or  atrophy.  On  the  other  hand,  it  may  result  from  a  connective- 
tissue  proliferation  compressing  the  glands. 

Musgrave  believes  an  atrophic  condition  of  the  intestines  may 
follow  the  chronic  catarrh  occurring  w4th  amebic  dysentery. 

The  villi  degenerate  with  the  atrophy  of  the  glands,  shrink,  and 
become  small.  No  ulceration  of  the  soHtary  or  agminate  follicles 
occurs,  and  it  is  a  question  whether  atrophy  to  any  extent  ever 
takes  place  in  them. 


CHRONIC    CATARRH    OF    THE)    INTESTINES  489 

There  is  a  degeneration  of  the  muscular  coat  and  some  thinning  of  it. 

Jiirgens^  has  described  a  fatty  degeneration  of  Meissner's  and 
Auerbach's  plexus  and  of  the  muscular  tissue,  as  a  special  type  of 
intestin?^  atrophy;  Sasaki  records  2  similar  cases  dying  with  the 
clinical  symptoms  of  pernicious  anemia.  These  conditions  probably 
are  related  to  intestinal  atrophy. 

Atrophy  of  the  mucosa  occurs  more  frequently  in  the  colon, 
especially  in  the  cecum,  ascending  colon,  or  ileum  near  the  valve. 
Large  portions  of  the  intestines  are  rarely  found  atrophied,  but  the 
process  generally  involves  certain  parts. 

Ulcerative  Processes. — As  in  acute  enteritis,  we  may  have  ulcerative 
processes  in  chronic  catarrh  of  the  intestines.  Superficial  erosions  of 
the  mucosa  may  become  deeper  with  the  production  of  ulcers. 
Rarely  they  increase  sufficiently  in  depth,  and  result  in  erosion  of  a 
blood-vessel  with  hemorrhage,  or  cause  a  local  peritonitis  with  or 
without  abscess,  or  even  a  perforative  peritonitis.  Generall)^  the 
ulcers  remain  unchanged  for  a  considerable  time  or  cicatrize;  occa- 
sionally stricture  of  the  intestines  may  result.  The  follicles  may 
occasionally  swell  up  and  burst,  producing  small  follicular  ulcers. 
Frequently  healing  takes  place.  Extensive  ulcerations  are  seldom 
met  with  in  chronic  enteritis,  unless  accompanying  a  tubercular 
process. 

The  "sago  grains"  or  frog  spawn  in  the  feces,  formerly  believed 
pathognomonic  of  follicular  ulceration,  are  shown  to  be  of  vegetable 
origin. 

Kitagawa  finds  that  some  of  these  grains  are  mucous  in  character, 
but  this  in  itself  militates  against  ulceration,  as  ulcers  do  not  discharge 
mucus,  but  pus.     The  presence  of  mucus  merely  indicates  catarrh. 

Symptoms. — The  chief  diagnostic  symptom  of  chronic  intestinal 
catarrh  is  the  abnormal  character  of  the  feces.  It  seems  advisable 
to  first  describe  the  subjective  and  objective  symptoms  which  occur 
in  many  cases.  Some  patients  complain  of  no  subjective  symptoms 
whatever.  The  majority  of  cases  complain  of  a  feeling  of  discomfort 
or  occasionally  of  slight  pains  in  the  abdomen.  These  symptoms  are 
apt  to  be  most  marked  after  eating,  usually  several  hours;  or  fre- 
quently just  before  or  even  after  defecation.  At  times  these  sensa- 
tions may  disturb  the  patient  an  hour  or  two  before  rising. 

There  is  a  feeling  of  tension  or  bloating  of  the  abdomen  which 
may  be  relieved  by  the  passage  of  flatus,  and  this  tendency  gives  rise 
to  considerable  annoyance.  Flatulence  may  become  so  severe  as  to 
cause  shortness  of  breath,  an  asthmatic  attack,  palpitation,  angina 
pectoris,  or  cerebral  congestion  and  vertigo,  all  of  which  symptoms 
are  alleviated  by  belching  of  gas.  Flatulence  is  much  more  charac- 
teristic of  chronic  enteritis  than  of  the  acute  type. 

Borborygmi  are  often  present.  Severe  pains  are  usually  absent, 
though  slight  colicky  pains  of  rather  brief  character  may  be  present. 
'  Berlin,  klin.  Wochenschr.,  1892,  p.  357. 


490  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

These  are  often  relieved  by  bowel  movement  or  by  the  expulsion  of 
flatus. 

In  some  cases  the  general  health  is  not  impaired;  while  in  other 
cases  it  is  undermined.  General  nutrition  may  become  impaired, 
especially  if  the  small  intestine  is  also  involved.  In  the  latter  case 
gastric  symptoms,  such  as  anorexia  and  nausea,  and  occasionally 
vomiting,  may  be  met  with. 

The  patient  may  feel  weak,  disinclined  to  work,  be  irritable, 
depressed,  and  even  hypochondriac  or  melancholic.  There  may  be 
loss  of  weight,  anemia,  slow  pulse,  cold  extremities,  and  attacks  of 
severe  headache.  The  nervous  symptoms  are  due  in  part  to  depres- 
sion from  an  evidently  chronic  and  persistent  disease,  and  to  a  large 
degree  to  auto-intoxication. 

Physical  Signs. — The  abdomen  may  appear  distended,  especially 
a  couple  of  hours  after  eating,  with  some  tenderness  on  pressure. 
In  chronic  enteritis  the  colon  seems  to  be  more  usually  affected. 

Chronic  Catarrhal  Colitis. — There  may  be  chronic  catarrhal 
colitis,  with  tenderness  over  the  caput  coH  and  ascending  colon,  with 
the  sensation  of  a  hard  mass  which  yields  to  the  examining  finger 
on  pressure  (fecal  accumulation),  or  this  part  may  be  tympanitic 
and  give  the  splashing  sound  from  gas  and  Hquid.  The  same  may  be 
true  over  the  descending  colon,  sigmoid  flexure,  or  transverse  colon. 
There  is  often  tenderness  on  pressure  along  the  entire  colon.  Pain 
is  felt  directly  under  the  point  of  pressure,  or  occasionally  at  a  dif- 
ferent point  further  along  the  colon,  due  to  the  passage  of  gas, 
which  has  been  forced  along  by  local  pressure. 

In  thin  persons  peristaltic  movements  of  the  intestines  are 
occasionally  observed,  especially  after  palpation.  In  some  cases 
there  are  no  special  objective  symptoms. 

The  diagnostic  symptom  in  chronic  intestinal  catarrh  is  the 
abnormal  character  of  the  stool — the  presence  of  mucus. 

The  movements  are  irregular  and  the  consistence  of  the  stool  is 
variable,  hut  the  mucus  is  diagnostic.  Diarrhea  is  not  a  constant 
symptom. 

There  are  four  types  of  movements  which  occur  in  chronic 
enteritis : 

1.  In  one  set  of  cases  there  is  marked  constipation,  and  a  solid 
movement  occurs  only  once  every  two  or  three  days  and  at  times 
only  after  a  cathartic.  The  feces  are  usually,  hard.  It  is  probably 
due  to  a  diminished  activity  of  the  automatic  nervous  mechanism 
of  the  intestines  produced  by  the  catarrh  (Nothnagel). 

2.  In  others,  constipation  and  diarrhea  alternate;  there  may  be 
hard  movements  for  several  days  and  these  succeeded  by  five  or  six 
thin  or  mushy  movements,  mixed  with  mucus,  and  accompanied 
by  severe  colicky  pains.  These,  in  turn,  will  be  followed  by  con- 
stipation, and  so  on.  In  some  instances  the  evacuations  will  be 
fairly  normal  for  several  days  and  then  diarrheal  movements  will 


CHRONIC    CATARRH    OF    THE    INTESTINES  49 1 

occur  and  after  this  constipation.  Constipation  is  the  chief  feature 
in  these  cases.  The  reflex  irritabihty  of  the  nervous  apparatus, 
however,  is  quite  good,  and  decomposition  of  the  stagnating  bowel 
contents  eventually  causes  increased  peristalsis  with  diarrhea. 

The  periods  of  constipation  or  diarrhea,  on  the  other  hand,  may 
continue  for  a  long  time;  thus,  constipation  for  several  weeks  or 
months,  and  then  diarrhea  for  weeks  or  months.  Probably  in  the 
latter  class  there  is  an  acute  exacerbation  of  the  catarrh. 

3.  Rare  cases  occur  in  which  there  is  a  daily  evacuation  of 
unformed  and  mushy  feces. 

4.  Cases  in  which  for  months  the  patients  pass  several  diarrheal 
stools  each  day.  The  small  intestine  is  involved  as  well  as  the  large 
bowel,  as  there  is  a  bile-pigment  reaction,  as  a  rule,  or  there  are 
yellow  fragments  of  mucus  or  epithelial  and  round  cells  tinged  with 
bile.  The  food  on  account  of  the  catarrhal  process  is  not  completely 
digested  in  the  small  intestine,  and  abnormal  products,  such  as  acids, 
etc.,  are  produced,  so  that  the  undigested  food  and  fermenting 
material  give  rise  to  increased  peristalsis. 

In  addition  there  are  some  in  which  the  ner\^ous  element  is  a 
factor  combined  with  the  catarrh,  and  movements  occur  during  the 
night  or  early  in  the  morning.     F.  Delafield^  describes  this  type. 

The  presence  of  mucus  in  the  feces  is  characteristic.  The  type  of 
mucus  in  mucous  colic  (Enteritis  membranacea) ,  which  occurs  in 
large  amount,  and  the  symptoms  render  the  differential  diagnosis 
comparatively  easy.  In  other  cases  the  presence  of  mucus  demon- 
strates a  true  catarrh.  In  habitual  constipation  there  may  be  a  thin 
shellac-like  covering  of  mucus  over  the  scybalse,  and  this  appearance 
is  not  found  in  chronic  enteritis.  With  chronic  catarrh  with  con- 
stipation, the  quality  of  the  dejecta  may  be  nearly  normal,  except 
there  is  an  admixture  of  mucus.  In  rare  cases  the  mucus  may  be 
absent,  or  it  may  be  very  tough  and  adhere  to  the  intestinal  wall, 
or  the  scybalse  may  be  too  small  to  scrape  it  off.  However,  on  most 
occasions  mucus  will  be  present,  and  if  there  is  doubt,  washing  of 
the  bowel  by  means  of  the  tube  and  funnel  will  eventually  bring  it 
away. 

Besides  the  presence  of  mucus  in  mucous  colic,  in  some  cases  of 
intestinal  dyspepsia  there  is  mucus  in  the  stools. 

Intestinal  Dyspepsia.  Chronic  Enteritis. 

Pure  mucus  alone.     Stools  gelatinous.         Mucus  with  epithelial  and  round  cells 
Mucus     microscopic     and     seldom  (diagnostic), 

visible. 

Green   stools  with  acid  reaction;   bile- 
pigment  gives  pronounced  reaction. 

No  fecal  odor.  Alkaline  stools.     Fecal  odor. 

The  quantity  of  mucus  varies  greatly ;  in  most  cases  onlv  a  small 
or  moderate  amount. 

1  Med.  Record,  May  11,  1905. 


492  DISEASES   OF   THE    STOMACH    AND   INTESTINES 

The  various  combinations  of  mucus  with  the  stool  and  the  local- 
ization of  the  catarrhal  process  have  been  described  under  Acute 
Enteritis  (page  483),  to  which  I  refer  my  readers. 

We  may  have  therefore :  (i)  Chronic  catarrhal  enteritis  (alone), 
rare;  (2)  chronic  catarrhal  enterocolitis;  (3)  chronic  catarrh  of 
various  portions  or  of  the  entire  colon  or  of  the  rectum;  thus, 
chronic  catarrh  of  the  caput  coli,  of  the  ascending,  transverse,  or 
descending  colon ;  or  chronic  catarrhal  sigmoiditis,  or  proctitis.  The 
colon  is  most  frequently  involved. 

When  the  movements  are  watery  and  thin  the  fecal  matter  is  a 
light  brownish  yellow  or  grayish  yellow,  and  may  contain  little  biliary 
matter.  Undigested  meat  or  starch  particles  can  often  be  seen  in 
these  cases. 

Microscopically. — Though  nothing  may  be  discovered  macro- 
scopically,  we  may  find  with  the  microscope  undigested  meat-fibers, 
starch  granules  and  fat  droplets,  also  mucus  and  round  and  epithelial 
cells,  at  times  yellow  and  shrivelled  up.  They  indicate  catarrh  of 
the  small  intestine.  Blood  is  never  present  unless  due  to  ulcer  or 
hemorrhoids.     Pus  is  rarely  found  and  only  as  isolated  cells. 

Dejecta  resembling  pus  dilated  with  water  (Blennorrhoea  intes- 
tinalis)  shows  diphtheritic  inflammation  when  pus  is  seen  in  large 
amount  under  the  microscope.  Large  masses  of  epithelial  cells  in 
various  degrees  of  degeneration  are  present  in  chronic  catarrh. 
They  are  responsible  for  the  cloudiness  in  the  mucous  secretion. 

The  character  of  the  food  and  of  the  stool,  and  whether  there  is 
constipation  or  diarrhea,  determine  the  consistence  and  reaction 
of  the  feces  and  the  degree  of  fermentation.  As  a  rule,  alkaline 
reaction  is  present.  The  presence  of  fermentation  and  putrefaction 
can  be  determined  by  the  abdominal  tension,  flatus,  and  character 
of  the  stool,  which  may  be  fetid  and  present  a  foamy  surface. 

Fecal  material  may  be  placed  in  a  fermentation  tube  and  kept 
at  blood  temperature  for  several  hours,  and  the  degree  of  fermenta- 
tion or  putrefaction  will  be  shown  by  the  quantity  of  gas  in  the 
tube.  The  method  is  described  under  ' '  Testing  the  Intestinal 
Functions." 

The  presence  of  putrefaction  will  be  shown  by  indican  in  the 
urine,  and  the  Rosenbach  reaction  (Burgundy  red)  on  the  addition 
of  nitric  acid  and  boiling. 

A  chronic  catarrhal  enteritis  complicated  with  ulcers  will  show 
marked  diarrhea  with  pus  and  blood  in  the  stool.  If  the  ulcers  occur 
in  the  small  intestine  alone  and  there  is  no  diarrhea,  pus  and  blood 
often  will  not  he  present;  but  there  will  be  more  severe  pain,  more 
marked  tenderness  on  pressure,  and  the  clinical  symptoms  will  be 
more  severe. 

The  diagnosis  of  the  atrophic  type  of  chronic  enteritis  is  extremely 
difficult.  Some  question  its  possibility.  There  will  be  a  previous 
history  of  intestinal  catarrh  of  long  standing.     Later  there  will  be 


CHRONIC   CATARRH   OF  THE    INTESTINES  493 

diarrhea,  no  mucus,  with  gradual  loss  of  weight,  and  at  times  symp- 
toms of  pernicious  anemia.  Tuberculosis  must  be  excluded.  This 
condition  is  more  frequent  in  the  young. 

Course. — The  course  of  chronic  intestinal  catarrh  is  usually  very 
tedious.  It  may  last  for  many  years.  There  may  be  periods  of 
perfect  health,  but  there  is  a  tendency  to  relapses  from  any  slight 
indiscretion. 

Differential  Diagnosis. — The  method  of  localization  of  the 
catarrh,  as  previously  stated,  is  the  same  as  in  acute  enteritis  (page 

483). 

Irregular  bowel  action,  with  the  presence  of  mucus  in  the  stools 
of  the  character  described,  associated  with  abdominal  symptoms  of 
discomfort,  suggest  chronic  catarrh.  The  discharge  of  mucous  colic 
is  characteristic,  as  are  also  the  symptoms.  In  the  mucus  which  is 
occasionally  found  with  intestinal  dyspepsia  there  is  an  absence  of 
epithelial  and  round  cells  and  the  stools  are  green  and  acid,  as  I 
have  already  stated. 

In  habitual  constipation  there  is  an  absence  of  mucus  in  the  move- 
ments. With  marked  fecal  impaction  I  have  frequently  seen  a  small 
amount  of  mucus  in  the  feces  due  to  temporary  irritation.  After 
removal  of  the  impaction  and  subsequent  care  of  the  bowels  there  is 
no  further  appearance  of  mucus.  Impaction  if  neglected,  or  occur- 
ring in  frequent  attacks,  may  be  a  cause  of  local  intestinal  catarrh 
and,  as  heretofore  noted,  occasionally  of  stercoral  ulcers. 

With  malignant  disease  of  the  intestines,  enteritis  is  often  asso- 
ciated, but  the  cachexia  is  marked  and  other  symptoms  of  the  neo- 
plasm are  present.  With  intestinal  ulcers  there  are  marked  pains, 
local  tenderness,  and  pus  and  blood  in  the  stool.  With  enteroptosis 
we  may  have  a  prolapse  of  the  sigmoid,  fecal  accumulation,  and 
chronic  catarrhal  sigmoiditis.  In  every  case  of  chronic  intestinal 
catarrh,  enteroptosis  should  be  examined  for. 

Rectal  examination  should  be  made  in  every  case  of  chronic  intestinal 
catarrh,  as  the  focus  occasionally  starts  from  the  rectum  and  pro- 
gresses up  the  bowel  as,  for  example,  from  an  ulcer.  On  account  of 
its  importance  I  shall  devote  a  brief  chapter  to  Proctitis. 

~  A  uterine  fibroid  may  block  the  bowel,  acting  as  a  ball-valve, 
and  from  fecal  accumulation  above  this  point  a  marked  catarrh  of 
the  mucous  membrane  may  result. 

Chronic  appendicitis  may  result  from  a  chronic  intestinal  catarrh ; 
while  in  some  cases  a  chronic  appendicitis  may  act  as  a  focus  of  irrita- 
tion for  a  localized  chronic  catarrh  in  the  cecum.  Removal  of  the 
appendix  is  curative  in  the  last  type.  In  certain  diseases  of  the 
stomach  there  may  be  constipation  or  diarrhea,  but  the  absence  of 
mucus  in  the  stools  and  examination  of  the  gastric  contents  will 
settle  the  question. 

In  chronic  enteritis  of  the  small  intestine  alone  there  are  usually 
gastric  symptoms,  constipation,  yellow  tinged  mucus  in  the  stools, 


494  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

generally  microscopic  and  well  mixed  with  the  feces,  and  the  biliary 
salts  reaction. 

In  chronic  catarrhal  colitis  there  is  usually  more  constipation 
and  more  or  less  mucus  of  a  grayish  tinge,  either  covering  or  on  the 
surface  of  the  feces  or  in  small  strings.  Pure  mucus  may  at  times 
be  voided  at  the  end  of  defecation  if  the  lower  bowel  is  affected. 
Palpation  is  of  value  in  locating  the  position  of  the  chronic  colitis, 
as  the  affected  area  is  apt  to  be  sensitive  to  pressure. 

Chronic  diarrhea  is  prominent  in  cases  in  which  both  the  small 
and  large  intestines  are  involved,  and  the  mucus  ma}^  be  yellow  in 
color  and  considerable  undigested  food  is  often  present. 

Prognosis. — This  depends  on  the  severity  of  the  symptoms,  the 
duration  of  the  disease,  and  the  physical  condition  of  the  patient. 

In  the  very  young,  very  old,  or  those  weakened  by  some  other 
disease,  such  as  endocarditis  or  tuberculosis,  severe  types  of  chronic 
catarrh  may  be  accessory  in  producing  a  fatal  result. 

As  a  rule,  the  prognosis  as  to  life  is  favorable,  but  in  the  severer 
cases  of  long  standing  it  is  not  so  favorable  as  to  perfect  cure. 

The  cases  have  a  tendency  to  relapse,  especially  after  indiscre- 
tions, though  they  may  continue  for  a  considerable  time  with  com- 
parative comfort.  The  milder  cases  of  not  long  standing  may 
recover  under  appropriate  treatment. 

Treatment. — The  cause  of  the  chronic  catarrh  should  be  care- 
fully sought, out  and  corrected.  If,  for  example,  endocarditis  with 
resulting  circulatory  disturbances  (which  are  a  predisposing  factor) 
be  present,  this  should  receive  treatment.  The  Nauheim  bath,  even 
though  taken  at  home  by  means  of  the  Triton  salts,  would  be  of  value 
in  such  cases.  If  enteroptosis  be  present,  such  as  in  the  case  I  have 
described,  where  there  was  marked  prolapse  of  the  sigmoid,  fecal 
accumulation,  and  local  chronic  catarrh,  treatment  by  abdominal 
support  (Rose's  belt)  and  increasing  the  nutrition  by  the  methods 
described  under  Gastroptosis  would  be  indicated,  in  addition  to  the 
general  treatment  for  chronic  catarrh.  I  have  seen  one  obstinate 
case  cured  by  S.  Gant  by  drawing  up  and  suturing  the  sigmoid  to  the 
abdominal  muscles.  Angulations  of  the  sigmoid  should  be  cor- 
rected.    If  worms  are  present,  they  should  be  removed. 

These  remarks  will  sufficiently  illustrate  the  necessity  for  investi- 
gation of  the  cause  of  the  catarrh.  Hygienic  and  dietetic  measures 
are  of  great  importance. 

The  patient  should  regulate  his  life  carefully,  not  overwork  nor 
be  under  too  great  business  strain,  eat  slowly  and  at  regular  hours, 
and  live  in  the  open  air  as  much  as  possible.  In  the  constipated  cases 
considerable  exercise  is  of  value.  When  the  diarrhea  is  marked  the 
patient  should  keep  quiet  during  its  active  stage,  and  in  some  cases 
remain  in  bed  until  it  has  passed.  Ner\^ous  disturbances  should  be 
avoided.  The  patient  should  exercise  care  not  to  wet  the  feet  or 
undergo  exposure  to  cold,  and  should  be  properly  protected  in  rainy 


CHRONIC    CATARRH    OF   THE    INTESTINES  495 

weather.  A  flannel  band  about  the  abdomen  is  of  value.  Change 
of  scene  and  climate  are  often  sersdceable. 

Diet. — The  patient  should  eat  at  regular  hours,  slowly,  and 
masticate  thoroughly.  It  is  preferable  to  give  small  meals  more 
frequently  than  three  large  meals,  and  sufficient  nourishment  should 
be  administered  so  that  there  is  an  increase  in  weight. 

Fried  foods,  hot  breads,  rich  pastries,  desserts,  and  indigestible 
substances  should  be  avoided.  Though  some  allow  the  very  moder- 
ate use  of  light  wines,  and  occasionally  beer  or  ale,  in  constipated 
cases,  and  the  use  of  claret  in  diarrhea,  in  my  own  experience  I  find 
that  patients  with  catarrhal  conditions  of  the  gastro-intestinal  tract 
do  much  better  by  eliminating  alcoholic  beverages  altogether. 

The  character  of  the  diet  is  dependent  upon  whether  diarrhea  or 
constipation  is  present. 

In  diarrheal  cases,  if  the  type  be  severe,  milk  and  Hme-water 
equal  parts,  or  boiled  milk,  or  milk  and  barley-water,  or  rice-water  in 
combination  often  are  efficacious;  though  some  patients  have  an 
idiosyncrasy  to  milk. .  Rest  in  bed  for  a  brief  period  may  be 
necessary. 

Kumyss,  matzoon,  bacillac,  or  lactone-buttermilk  are  often  use- 
ful in  such  cases,  though  with  some  these  preparations  are  objection- 
able, increasing  the  diarrhea.  Sanatogen  in  5j  (4.0)  doses,  also  raw 
eggs  beaten  in  milk,  may  be  of  value. 

In  milder  cases  of  diarrhea  the  diet  may  be  more  liberal.  Car- 
bonated waters,  lemonade,  fruits,  salads,  acids,  cabbage,  cauH- 
flower,  rye  bread,  brown  bread,  ice-cream,  pastries,  oatmeal,  green 
vegetables,  corn  and  beans,  turnips,  carrots,  beets,  radishes,  celery, 
and  lobster  should  he  avoided.  Mashed  and  baked  potatoes,  rice, 
sago,  macaroni,  bread  well  baked  and  toasted,  with  a  moderate 
amount  of  butter,  cream  soups,  bouillon,  soft-boiled  or  scrambled 
eggs,  sweet-breads,  calves'  brains,  chicken,  lamb  chops,  lean  fish, 
cocoa,  tea  and  milk,  or  matzoon  (with  some)  can  be  given. 

The  drink  should  not  be  too  hot  or  too  cold,  and  an  excess  of 
liquid  should  be  avoided. 

In  constipated  cases  the  diet  must  be  more  liberal.  In  addition 
to  the  food  mentioned  above,  fruits,  such  as  oranges,  ripe  pears, 
grapes,  green  vegetables,  such  as  spinach,  peas,  lettuce,  cauliflower, 
plenty  of  butter,  cream,  and  fluids  are  of  service. 

Cabbage,  cucumbers,  brown  bread,  sausages,  lobster,  mayon- 
naise dressing,  and  bran  breads  should  be  avoided  in  these  cases 
also. 

The  urine  findings  should  modify  the  diet — if  indicanuria,  less 
meat  or  none  for  a  time;  if  fermentation,  less  vegetables;  if  nephritis, 
an  appropriate  diet. 

Massage. — In  cases  characterized  by  chronic  constipation,  gentle 
massage  over  the  course  of  the  colon  or  the  use  of  a  light  cannon-ball 
is  indicated.     No  pressure  should  be  exerted  on  the  ball,  but  it  should 


496  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

be  rolled  along  the  colon  for  five  minutes  morning  and  night.  Light 
vibratory  massage  is  of  value  under  similar  conditions. 

Hydrotherapy. — Warm  salt  baths  at  98°  to  100°  F.,  or  Nauheim 
baths  (artificial)  eight  to  ten  minutes  every  other  day  for  two  or 
three  weeks,  or  pine-needle  baths,  bran  baths,  or  mud  baths  may  be  of 
some  service  in  some  diarrheal  cases.  Cold  baths  should  be  avoided 
in  diarrhea.  A  Priessnitz  wet  pack  over  the  abdomen  is  of  value 
when  applied  on  retiring. 

Cold  showers  and  cold  sponges  are  of  service  in  nervous  cases. 
Cold  sitz-baths  and  cold  douches  over  the  abdomen  are  of  use  in 
constipated  cases,  but  should  be  preferably  carried  out  at  some 
sanitarium.  I  have  rarely  found  the  latter  methods  necessary,  but 
use  the  artificial  Nauheim,  pine-needle,  or  bran  baths,  also  the  cold 
compress  to  a  considerable  extent. 

Mineral  Waters. — A  methodic  course  of  drinking  certain  alkaline 
or  saline  mineral  waters  has  proved  beneficial  in  many  cases.  When 
taken  at  the  springs,  the  patient  is  obliged  to  follow  a  rational  method 
of  life  and  diet  and  is  free  from  worry,  and  thus  receives  additional 
benefit.  Carlsbad  is  especially  valuable  when  there  is  a  tendency  to 
diarrhea,  and  Vichy  is  next. 

In  cases  of  marked  constipation,  Marienbad  is  of  service,  and  also 
the  Hawthorne  and  Congress  Springs  at  Saratoga.  Virginia  Hot 
Springs  are  also  to  be  recommended.  Where  neither  diarrhea  nor 
constipation,  are  prominent,  Kissengen  or  Homberg;  with  constipa- 
tion and  anemia,  Franzensbad  and  Klster. 

Carlsbad  water  should  be  taken  in  small  quantities,  a  wineglassful 
twice  a  day,  or  even  in  small  amounts  of  the  imported  salts,  gr.  30  to 
60,^  three  to  five  times  a  day.  It  is  preferable  to  begin  with  small 
doses.  Some  do  badly  with  this  method.  If  the  diarrhea  increases 
so  that  the  patient  begins  to  lose  weight,  the  treatment  should  be 
stopped  at  once. 

Medication. — The  method  of  internal  medication  depends  upon 
whether  constipation  or  diarrhea  is  the  existing  condition.  As  a 
preliminary  it  is  always  wise  to  begin  treatment  with  a  thorough 
cleansing  of  the  intestines  by  a  single  dose  of  castor  oil,  oiss  (45.0),  or 
a  good  dose  of  Carlsbad  salts  or  magnesium  sulphate. 

If  there  be  marked  fecal  accumulation,  it  is  better  first  to  employ 
enteroclysis  or  enemata,  to  remove  the  impaction,  and  then  follow 
with  the  single  cathartic. 

In  constipated  cases,  fruits,  buttermilk,  cold  water  (glass)  on  rising, 
stewed  fruits,  and  a  regular  hour  for  attempted  stool  are  all  rational. 

An  enema,  olive  oil,  Siv  (125.0),  increasing  to  Oj  (500  cc.)  or 
more,  given  slowly  by  a  long  tube  on  retiring,  and  to  be  retained,  is 
an  excellent  procedure.  It  may  be  necessary  to  employ  soapsuds 
enema  (never  over  i  quart)  or  normal  salt  solution.  Rhubarb 
pills,  fluidextract  of  cascara  in  5j  (4.0)  doses,  or  the  same  quantity 
1  An  equivalent  of  2.0  to  4.0  of  the  salts. 


CHRONIC    CATARRH    OF   THE)    INTESTINES  497 

of  aromatic  fluidextract  cascara,  or  podophyllin  pills  are  of  service. 
Carlsbad  water  has  been  given  by  enema. 

Small  doses  of  castor  oil  or  olive  oil  combined  with  salol  are  of 
considerable  value  in  all  cases.     Thus : 

Salol,  gr.  5  (0.3)  tablet;  with  it  give  castor  oil.lUx  (0.59),  given  in 
a  gelatin  capsule,  coated  with  shellac,  four  times  a  day;  or  olive  oil 
can  be  substituted. 

In  the  constipated  cases  larger  doses  of  olive  oil  by  mouth,  oj 
to  iv  (30.0-125.0)  t.  i.  d.,  are  of  service. 

The  oil  preparations  seem  to  have  an  excellent  effect  on  the  mucous 
membrane.     Lead  and  zinc  preparations  I  do  not  employ. 

Nitrate  of  silver  is  sometimes  of  service.  It  can  be  given  in 
aqueous  solution,  each  5j  containing  |  to  ^  gr.  (0.0 11 -0.0 16),  being 
kept  in  a  dark  bottle,  or  the  same  dosage  in  an  enteric  coating. 

The  following  pill,  gr.  ^  (0.008),  of  silver  nitrate  is  excellent: 

Bf.     Argenti  nitratis gr.  v  (0.3) 

Resin  turpentine  "1  ..,-.,. 

Liq.  potass.  |   aa  o]  (4.0) 

Pulv.  licorice q.  s. — M. 

Div.  in  pil.  No.  xl. 
Sig.— One  pill  t.  i.  d. 

Bismuth  salicylate,  gr.  5  to  10  (0.3-0.6)  t.  i.  d.,  is  of  some  value,  but 
a  movement  should  be  secured  every  day  if  it  is  given  in  the  con- 
stipated cases. 

The  bismuth  and  tannin  preparations  are  of  special  value  in  the 
diarrheal  cases,  the  dosage  being  dependent  on  their  severity.  The 
movements  should  be  reduced  to  one  or,  at  the  most,  two  a  day. 
Opiates  I  always  avoid,  if  possible. 

Bismuth  subnitrate,  gr.  10  to  20  (0.6-1.3)  three  or  four  times  a 
day  or  more,  alone  or  combined  with  chalk. 

Bismuth  salicylate,  gr.  5  to  10  (0.3-0.6)  t.  i.  d.,  combined  with 
subnitrate  bismuth;  or  bismuth  subcarbonate,  gr.  10  to  20  (0.6-1.3) 
t.  i.  d. ;  or  bismuth  subgallate,  gr.  5  to  10  (0.3-0.6)  t.  i.  d. 

Tannigen,  tannalbin,  or  tannopin,  gr.  5  to  15  (0.3-1.0)  t.  i.  d. 

Beta-naphtol-bismuth,  gr.  5  (0.3)  three  or  four  times  a  day,  if 
there  is  fermentation.  For  some  of  the  combinations  with  kino- 
catechu,  etc.,  I  refer  to  treatment  of  Acute  Enteritis. 

Belladonna  can  be  used  for  pains,  but  codein  and  morphin  rarely 
should  be  employed. 

Local  Treatment. — This  is  of  great  importance,  especially  when 
the  large  intestine  is  involved,  which  is  usual.  The  method  may  be 
employed  by  an  enema  of  i  pint  (500  cc.)  to  i  or  even  2  quarts 
(liters)  of  the  solution,  preferably  employing  several  quarts  (liters), 
with  the  recurrent  tube  or  two  tubes.  If  possible  I  use  my  own 
rectal  irrigator  of  hard  rubber  or,  if  the  rectum  is  sensitive,  'the 
soft-rubber  tube  or  two  catheters. 

Normal  saline  solution — oj  (4.0)  salt  to  Oj  (500  cc.)  water ^ — at 
1  Oil  of  peppermint  (10  drops)  can  be  added  to  this. 
32 


498  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

105°  to  110°  F.  is  excellent  if  there  is  much  pain,  or  flaxseed  tea  at 
the  same  temperature  is  useful.  Slippery  elm  solution  and  gum- 
arabic  solution  are  excellent  soothing  applications. 

Listerin,  glycothymolin,  borolyptol,  and  boric  acid,  5j  to  ij 
(4.0-8.0)  to  the  quart,  are  of  service. 

Tannin,  gr.  10  to  20  (0.6-1.3)  to  the  quart  (liter);  zinc  sulpho- 
carbolate,  gr.  10  to  15  (0.6-1.0);  or  borax,  oj  (4-0)  to  the  quart,  are 
good  astringents;  salicylic  acid,  gr.  15  (i.o)  to  the  quart  (liter); 
irrigation  once  a  day  or  every  other  day  is  of  value. 

I  often  employ  flaxseed  tea  or  gum-arabic  one  day,  and  one  of 
the  mild  antiseptics  or  astringents  the  following  day. 

In  obstinate  cases,  nitrate  of  silver  solution,  gr.  10  to  20  (0.6-1.3) 
to  a  quart  (liter),  given  once  or  twice  a  week,  is  a  valuable  adjunct. 
If  the  patient  complains  of  pain,  a  subsequent  injection  of  normal 
saline  solution  is  of  service. 

The  bowels  should  be  thoroughly  emptied,  preferably  an  enema 
given  an  hour  or  two  before  local  treatment. 

Protargol  or  argyrol  (i :  1000  or  i :  1500)  is  of  service  in  place  of 
the  silver  nitrate. 

Surgery. — In  cases  with  evident  ulceration ,  if  no  benefit  results 
from  medical  treatment  conscientiously  applied  for  a  year,  I  would 
advocate  appendicostomy  or  cecostomy  with  subsequent  irrigations. 
In  catarrh  without  ulcers  I  do  not  believe  operation  is  indicated. 

PROCTITIS 

The  rectum  is  very  liable  to  bacterial  infection,  both  from  within 
and  without,  through  the  anal  opening,  so  that  ulcerations  and  peri- 
proctitis may  occur.  I  will  briefly  refer  to  this  disease,  merely  to 
serve  as  an  index  to  the  practitioner. 

Etiology. — As  this  condition  is  often  a  part  of  chronic  enteritis, 
the  etiologic  factors  may  be  identical.  Local  conditions  may  also 
produce  it;  thus,  traumatism,  as  by  a  syringe-tip;  sodomy;  impacted 
feces ;  worms ;  foreign  bodies  introduced  through  the  rectum  or  lodged 
there  during  their  passage  from  above,  such  as  fish-bones,  pins,  etc., 
hemorrhoids,  polypi;  prolapse,  intussusception;  tumors;  pressure 
from  other  organs;  displacement  of  the  uterus;  stone  in  the  bladder; 
inflammation  of  adjacent  organs,  such  as  uterus,  tubes,  prostate, 
or  seminal  vesicles.  Sitting  on  cold  stones  or  wet  seats  may  be  a 
cause.     Idiosyncrasies  to  certain  foods  seem  to  be  a  factor. 

Proctitis  is  classified  as  follows : 

1.  Acute  simple  catarrhal  proctitis. 

2.  Chronic  proctitis :   Atrophic  form ;  hypertrophic  form. 

3.  Specific  forms:  Gonorrheal,  dysenteric,  diphtheritic,  erysipel- 
atous, and  syphilitic  proctitis. 

Pathology. — With  simple  catarrh  there  is  no  pus,  except  pos- 
sibly a  minute  amount.     With  ulceration  there  is  pus  and  blood. 


PROCTITIS  499 

The  acute  and  chronic  types  of  intestinal  catarrh  have  aheady 
been  described.  It  is  preferable  to  examine  pus  (if  such  is  present) 
for  gonorrhea,  especially  if  there  be  a  gonorrheal  vaginitis,  and  it  may 
even  pass  by  extension  from  Bartholin's  glands. 

Erysipelas  may  extend  from  without.  Pseudomembranes  occur 
with  the  diphtheritic  type.  Amebse,  or  the  bacilli  dysenteric,  are 
found  with  the  dysenteric  type.  We  may  have  the  primary  chancre 
of  syphilis  in  the  rectum,  in  which  case  relaxation  of  the  sphincter 
will  also  be  noted,  or  there  may  be  secondary  ulceration  and  catarrh. 
The  test  for  Wassermann's  reaction  should  be  made  if  syphilis  is 
suspected.     Actinomycosis  may  rarely  occur. 

Symptoms. — They  have  been  described.  They  are:  Marked 
straining  and  tenesmus;  passage  of  mucus  with  the  stool,  or  mucus 
alone  with  pus  and  blood  if  ulceration  is  present ;  frequent  micturi- 
tion ;  throbbing  heat  and  weight  in  the  rectum.  Constipation  at  first, 
later  diarrhea;  heavy  and  aching  pain  in  the  rectum  and  down  the 
limbs ;  often  pruritus  and  prolapse  of  the  rectal  mucous  membrane 
or  hemorrhoids ;  temperature ;  coated  tongue ;  abscesses  of  the  rectum 
may  develop. 

The  chronic  cases  present  less  severe  symptoms. 

Digital  examination  is  painful  on  account  of  spasm,  and  the  rectum 
will  be  found  to  be  very  sensitive  and  hot  to  the  feel.  If  the  inflam- 
mation extend  deeper  into  the  tissues,  it  will  feel  hard  and  rigid. 

By  speculum  examination  it  will  be  seen  to  be  a  deep  red,  with 
hemorrhages  and  erosions.  Often  the  condition  is  so  painful  that  it  is 
not  advisable  to  use  a  speculum  at  first.  The  chronic  cases  run  a 
less  severe  course.  Complications :  Periproctitis  or  ischiorectal  ab- 
scess may  occur. 

Treatment. — Recurrent  rectal  irrigation  with  hot  normal  saUne 
solution  at  iio°  F.,  or  in  other  cases  with  cold  saline  solution  at  50° 
to  70°  F.,  with  the  patient  in  the  Sims  posture  for  fifteen  minutes' 
duration,' is  of  value,  once  or  twice  a  day,  to  relieve  inflammation. 
Flaxseed'-tea  irrigation  is  also  useful,  or  the  other  antiseptics 
described  under  Chronic  Enteritis. 

Injection  of  hvdrastis,  i  to  2  per  cent.,  or  aqueous  fluidextract 
of  krameria  (J.  P.  Tuttle),  5  to  20  per  cent.,  several  quarts,  are  of 
service  in  some  cases. 

Carbolic  acid  solutions  should  never  be  employed. 
In  the  acute  conditions  I  do  not  care  to  employ  nitrate  of  silver 
at  first,  though  later  i :  2000  every  day  or  two  is  of  value. 

Argyrol  or  protargol  (i :  500  or  i :  1000)  is  less  irritating.  Tuttle 
suggests  the  use  of  the  following  by  injection  to  quiet  irritation  after 
local  treatment. 

R.     Flaxseed  tea o j  (300) 

Opium  gr.  ss  to  J  (0.032-0.065) 

Aqueous  fl.  ext.  krameria Tdxxx  (1.77).— M. 

A  suppositorv  of  opium  and  iodoform  may  be  substituted. 


500  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

If  there  is  marked  purulent  inflammation,  then  twice  daily  irri- 
gate with : 

Peroxid  of  hydrogen  8  to  lo  per  cent.,  or  i :  looo  acetozone  or 
alphazone,  or  even  i :  10,000  bichlorid  of  mercury  once  in  twenty- 
four  hours. 

The  bowel  should  be  irrigated  well  with  saline  solution  after  each 
movement  and  medicated  solutions  used  once  or  twice  a  day. 

Injections  of  starch  and  laudanum  should  only  be  used  once  or 
twice  a  day  in  severe  cases  to  relieve  irritability. 

After  the  acute  stage  has  passed,  S.  Gant  recommends  spraying 
the  rectum  with  permanganate  of  potassium  (1:3000),  or  with 
zinc  sulphate,  copper  sulphate,  or  nitrate  of  silver,  i  per  cent. 

In  chronic  cases  irrigation  with  nitrate  of  silver  (i :  2000  to 
1 :  4000)  is  of  value,  every  two  or  three  days. 

I  have  seen  an  excellent  result  in  a  severe  chronic  case  from  the 
injection  of  the  aqueous  fluidextract  of  krameria,  suggested  by  J.  P. 
Tuttle.     His  formula  is  as  follows: 

Macerate  i  pound  of  bark  of  krameria  in  a  long  percolating  tube 
for  twenty-four  hours.  After  this  a  mixture  of  glycerin  (20  per  cent.) 
and  w-ater  (80  per  cent.)  is  ahowed  to  percolate  through  it.  The 
percolate  should  be  constantly  stirred  and  refiltered  through  the 
bark  a  second  time. 

The  filtrate  is  then  evaporated  down  to  i  pound,  thus  obtaining 
an  aqueous  fluidextract  containing  gram  for  gram  all  the  therapeutic 
properties  of  the  bark.  The  preparation  should  be  kept  in  a  dark 
place  and  not  exposed  to  air. 

A  10  to  20  per  cent,  solution  of  this  can  be  used  for  irrigation  or 
a  local  application  of  it  pure. 

The  diet  and  internal  medication  should  be  the  same  as  described 
tinder  Chronic  Enteritis.     Syphilis,  if  present,  should  be  treated. 

Warm  sitz-baths  aid  in  relieving  pain. 

PHLEGMONOUS   (PURULENT)   ENTERITIS 

This  disease,  a  purulent  inflammation  of  the  submucous  tissue 
of  the  intestines,  is  rare  as  a  primary  process.  It  is  probably  due  to 
streptococcic  infection,  the  jejunum  being  most  frequently  involved. 
Peritonitis  is  present,  but  the  purulent  enteritis  cannot  be  diagnosed 
as  the  cause,  in  my  opinion,  until  after  operation.  Phlegmonous 
enteritis  may  be  secondary  to  intestinal  ulceration,  to  intussuscep- 
tion, or  strangulated  hernia.  MaragHano  has  reported  septic  infection 
of  the  ileum  probablv  bv  the  colon  bacillus,  with  hemorrhage,  ulcer- 
ation, and  peritonitis. 


CHAPTER  XXIV 
DYSENTERY 

Dysentery  is  defined  as  an  infectious  disease  characterized  by 
specific  ulcerations  of  the  large  intestine.  In  typic  acute  cases  it 
gives  rise  to  bloody  mucous  or  mucopurulent  dejections,  accom- 
panied by  tenesmus  and  general  symptoms. 

Dysentery  was  known  to  the  ancient  world,  being  first  described 
accurately  by  Hippocrates  430  b.  c,  and  later  by  Celsus,  Aretaeus, 
and  Galen. 

In  1506  the  first  records  of  post-mortem  examinations  of  dysen- 
teric subjects  were  published  in  the  posthumous  work  of  Antonio 
Benevieni.  Following  these  came  many  writers,  among  whom  I 
shall  mention  a  few  of  the  most  prominent  of  recent  years :  Cruveil- 
hier,  Virchow,  Woodward,  Lambl,  Loesch,  KartuHs,  Quincke,  Roos, 
Mus'ser,  Osier,  Stengel,  Stockton,  Harris,  Councilman,  Lafleur, 
Ogata,  Shiga,  Russell,  Flexner,  His,  Barker,  Duval,  Bassett,  Yedder, 
Musgrave,  Strong,  Craig,  and  Thomas. 

It  has  been  demonstrated  that  the  disease  is  due  to  infections  of 
a  specific  type — either  to  the  ameba  dysenteriae  or  to  the  Bacillus 
dysenteriae  (Shiga)  or  one  of  its  strains.  The  disease  is  transmitted 
in  the  same  way  as  is  typhoid  fever.  It  sometimes  assumes  a  diph- 
theritic type,  in  which  case  other  bacteria  are  undoubtedly  associated. 

The  so-called  acute  catarrhal  dysentery,  the  sporadic  form, 
I  believe,  is  undoubtedly  due  to  the  Bacillus  dysenteriae  or  one  of  its 
strains.  '  Diphtheritic  dysentery  (or,  more  strictly  speaking,  pseudo- 
diphtheritic,  as  Klebs-Ldffler  bacillus  is  not  present)  has  been  shown 
in  many  cases  to  be  due  to  the  Bacillus  dysenteriae.  Undoubtedly 
mixed  infections  with  other  bacteria  are  found  in  this  type. 

DIPHTHERITIC  DYSENTERY 

This  may  be  found  in  combination  with  amebic  dysentery,  and. 
in  addition,  in  some  of  the  amebic  liver  abscesses  numerous  other 
bacteria  are  present,  which  demonstrate  mixed  infection  from  other 

sources. 

Secondary  diphtheritic  dysenter>'  is  a  common  terminal  event 
in  many  acute  and  chronic  diseases;  and  Vedder  and  Duval  have  de- 
monstrated that  the  Bacillus  dysenteriae  is  present  in  these  cases. 

Diphtheritic  dysentery  in  which  the  diplococcus  pneumoniae  has 
been  isolated  has  been  several  times  reported.  In  addition,  mercu- 
rial poisoning  or  uremia  may  have  this  lesion  associated.     It  is  evi- 

501 


502  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

dent,  therefore,  that  other  bacteria  either  present  in  or  entering  the 
intestinal  tract  under  favorable  conditions  may  produce  this  lesion. 

In  the  ileocolitis  of  infants  dysenteric  bacilli  of  various  strains 
have  been  discovered,  and  some  of  these  cases,  both  clinically  and 
pathologically,  present  the  appearance  of  an  acute  catarrh. 

Many  causes  were  formerly  given  for  the  production  of  dysentery, 
but  we  may  say  that  they  only  predispose  to  infection  on  account 
of  weakening  the  organism,  producing  intestinal  disturbances.  In 
the  case  of  overcrowding  in  asylums  and  camps  there  is  a  tendency 
to  unsanitary  conditions.  By  inattention  to  the  proper  relation  of 
the  latrines,  to  the  water-supply,  for  example,  there  may  result  a 

severe  epidemic. 

LOCATION 

Dysentery  is  found  in  all  parts  of  the  world,  but  is  endemic  and 
often  epidemic.  It  is  most  common  in  warm  climates,  such  as  the 
southern  United  States,  Cuba,  the  Philippines,  southern  coast-line 
of  Asia,  Africa,  Egypt,  Mexico,  Central  and  South  America.  It  has 
been  met  with  in  cold  climes,  as  in  North  Russia  and  Greenland; 
is  sporadic  in  all  parts  of  the  United  States  and  occasionally  epidemic. 
Severe  epidemics  have  occurred  in  the  New  England  States. 

During  the  Civil  War,  Woodward  collected  259,071  cases  of  acute 
dysentery  and  28,451  of  chronic  dysentery  in  the  Federal  service. 

During  the  recent  Spanish-American  War  the  mortality  from 
dysentery  and  typhoid  was  far  in  excess  of  that  from  battle;  and  in 
the  African  War  the  English  troops  suffered  severely.  In  the 
Russo-Japanese  War  the  deaths  in  the  Japanese  army  from  dysentery 
and  typhoid  were  infinitesimal  in  number,  demonstrating  that  by 
intelligent  care  of  the  water-supply  and  proper  sanitation  epidemics 
of  dysentery  can  be  absolutely  stamped  out. 

Dampness,  overcrowding,  and  imperfect  ventilation  vitiate  the 
system,  and  so  predispose  to  subsequent  infection.  With  over- 
crowding and  necessarily  insufficient  and  improper  attention  to 
sanitary  conditions,  infection  from  the  dejecta  can  readily  occur,  if 
a  sporadic  case  develop. 

Heat  and  moisture  predispose  to  intestinal  disturbances,  and 
readily  cause  changes  in  fresh  fruits  or  canned  material,  if  improperly 
cared  for,  which  in  turn  produce  diarrheal  disturbances,  and  cause 
susceptibility  to  infection.  Sudden  alternations  from  heat  to  cold 
produce  the  same  result.     Errors  in  diet  are  predisposing  causes. 

No  race  or  age  is  exempt  from  dysentery,  and  a  person  going  from 
his  native  to  a  warm  climate— with  the  sudden  change  in  food  and 
mode  of  life  incident  thereto — is  probably  more  susceptible. 

Dysentery  is  more  fatal  among  the  poor  and  ill-nourished  than 
among  the  rich,  though  the  latter  are  not  exempt.  It  is  probably 
more  prevalent  in  epidemic  and  endemic  form  in  smaller  country 
towns,  villages,  and  farms,  where  one  so  frequently  sees  the  well  in 
close  proximity  to  the  privy,  a  stagnant  pool,  or  the  family  cow-yard. 


DYSENTERY  503' 

Dysentery  may  be  endemic,   the  so-called   tropical  dysentery; 
epidemic  or  diphtheritic ;  and  sporadic  (the  acute  catarrhal  dysentery). 
It  is  classified  as  follows: 

1.  Amebic  dysentery,  in  which  there  is  at  times  a  mixed  infection 
(diphtheritic  process). 

2.  Bacillary  dysentery  (Shiga),  or  one  of  its  strains,  under  which 
are  included  the  sporadic  type  (acute  catarrhal),  which  probably 
belongs  to  this  classification,  as  a  catarrhal  type  (ileocoUtis)   exists 

in  infants.  .  .  . 

The  diphtheritic  type  is  included  and  also  the  secondary  dtphtheritic 
type,  which  may  be  a  terminal  event  in  acute  and  chronic  disease, 
and 'in  which  Vedder  and  Duval  have  demonstrated  the  presence  of 
the  Bacillus  dysenterige. 

Undoubtedly  other  varieties  of  bacteria  play  a  part  in  the  diph- 
theritic type. 

AMEBIC  DYSENTERY 
{Synonym. — Intestinal  Amebiosis.) 

Definition.— A  colitis,  latent,  subacute,  acute,  or  chronic,  caused 
by  the  ameba  dysenteric.  There  is  a  special  liability  to  formation 
of  abscess  of  the  liver. 

Often  these  cases  occur  without  the  clinical  symptoms  of  dysen- 
tery at  all.  I  agree  with  Musgrave  that  the  condition  should  be  more 
correctly  given  the  name  of  "intestinal  amebiosis." 

The 'disease  is  widely  prevalent  in  Egypt,  India,  the  Philippines, 
West  Indies,  Southern  States,  and  in  tropical  countries.  It  occurs 
frequently  in  the  United  States,  and  much  more  in  many  of  our  cities 
than  is  generallv  supposed.  I  have  recently  attended  a  case  clearly 
infected  in  New  York  State,  the  patient  having  never  been  south. 
It  is  endemic,  especially  in  warm  climates,  and  often  becomes  epi- 
■  demic.     Sporadic  cases  occur  in  temperate  climates. 

In  Manila,  Strong  states  that  out  of  1328  cases  in  the  United 
States  army,  561  were  of  the  amebic  type. 

At  the  Johns  Hopkins  Hospital,  Osier  reports  most  of  the  acute 
and  chronic  cases  of  dysentery  were  of  the  amebic  variety;  during 
the  first  fourteen  years  theie  were  119  cases  admitted,  95  of  which 
came  from  Maryland — 108  males  and  11  females. 

Source  of  Infection.— Chiefly  from  contaminated  water  or 
green  vegetables  and  fruit.  Musgrave  has  found  the  ameba  in 
ice-cream  and  water-ices. 

Amebse  Dysenterise.— Lambl  first  described  amebse  in  the  stools 
in  1859,  and  in  1875  Loesch  investigated  the  stools  of  a  dysenteric 
patient  and  described  the  amebae.  He  injected  the  stools  into  the 
intestines  of  dogs  and  produced  ulceration. 

Osier,  Councilman,  Lafleur,  Dock,  Quincke,  Roos,  Musgrave, 
Strong,  and  manv  others  have  carried  on  investigations. 

To  obtain  a  specimen  for  examination  little  flakes  of  mucus  or 


504  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

pus  should  be  selected,  or  the  mucus  may  be  secured  by  passing  a 
soft  catheter,  or  through  a  speculum.  Preferably  a  saline  cathartic 
should  be  administered,  as  suggested  by  Musgrave,  and  the  fluid 
portion  of  the  stool  examined  while  -warm.  Swollen,  altered  epithelial 
cells  must  be  distinguished  from  the  amebae.  The  cells  are  round 
with  granular  protoplasm. 

Ameba  dysenteriae  is  from  fifteen  to  twenty  microns  in  diameter 
and  consists  of  a  clear  outer  zone,  or  ectosarc,  and  a  granular  inner 
zone   (endosarc),  and  contains  a  nucleus  and  one  or  two  vacuoles 


^4: 


Fig.    202. — Amebae   from   a   culture.     Impression  preparation.      Borrel's   stain 
( Woolley  and  Musgrave) . 

(Fig.  202).  The  movements  are  similar  to  an  ordinary  ameba, 
consisting  of  a  slight  protrusion  of  the  protoplasm.  They  vary 
somewhat  and  can  be  intensified  by  having  the  slide  heated.  They 
have  a  pale  green  appearance  under  the  microscope.  Red  blood- 
corpuscles  are  at  times  contained  in  the  amebae,  and  occasionally 
bacteria. 

Musgrave  recommends  Borrel's  stain  for  study  of  amebae  in  the 
tissues. 

They  may  be  in  large  numbers  in  the  tissues.  In  the  pus  of  a 
liver  abscess,  amebae  may  be  abundant.     In  the   sputum  from  a 


■■.if 


^  >■  ^ 


>v>V 


¥'■  ^' 


■'•  i;  -^.^    .W>  ^  '   * 


/' 


/ 


4. 


>^^ 


Fig.  203. — Intestinal  amebiasis.    Cecum.     Shows  all  stages  of  ulceration.    The 
smallest  black  points  indicate  the  positions  of  preulcerative  lesions  (Woolley  and 

Musgrave). 


Fig.  208. — Intestinal  nmebiasis.     Rectum.     Extensive  ulceration  and  diphthe- 
ritis.     Thick-walled  gut  (Woolley  and  Musgrave). 


DYSENTERY  505 

pulmonary  infection  from   an  hepatic  abscess  they  can   be   recog- 
nized. 

Quincke  and  Roos  describe  three  varieties  of  amebae  in  the  stools 
of  healthy  persons;  and  Strong  two  types,  only  one  of  which  is 
pathogenic. 

Musgrave  and  Clegg  do  not  think  it  has  been  proved  there  are 
amebse  non-pathogenic  to  man.  They  hold  that  all  such  are,  or  may 
become,  pathogenic. 

Amebae  dysenterise  can  be  grown  in  cultures  from  stools  or 
intestinal  ulcers,  but  not  alone  as  a  pure  culture.  A  symbiotic 
organism  is  necessary  for  its  development.  It  has  been  isolated  as 
a  pure  culture,  in  combination  with  a  pure  culture  of  another  organ 
ism.  Fivea,  Celli,  and  ^liller  claim  to  have  grown  it  pure,  and 
that  it  multiplies  by  division. 

Resistant  forms  of  the  ameba  have  been  described  by  Cunningham 
and  Quincke.  They  are  apparently  analogous  to  the  gamete  forms 
of  the  malarial  parasite. 

The  "encvsted  amebse"  seem,  under  certain  conditions,  to  be 
necessary  for  the  transmission  of  the  disease  from  one  person  to 
another,  and  are  regarded  by  Musgrave  and  Clegg  as  the  most 
dangerous  type. 

Cultures  of  amebae  have  withstood  drying  for  fifteen  months. 

Location  of  Lesions. — The  lesions  are  found  in  the  large  intes- 
tine, rarely  in  the  lower  end  of  the  ileum ;  and  abscess  of  the  liver  is 
a  common  accompaniment,  being  present  in  22  per  cent,  of  Osier's 
cases. 

Pathology  of  Amebic  Dysentery. — Intestines. — Thoughwriters 
refer  to  the  classic  undermined  type  of  ulcer  in  amebic  dysentery, 
three  tvpes  of  lesions  are  described,  which  ma}-  shade  gradually  into 
each  other: 

1.  P re-ulcer ation. — This  stage  is  characterized  by  the  presence 
of  the  "small  red  dots"  of  Rogers,  varying  from  0.2  to  0.5  mm.  in 
diameter,  and  which  are  intensely  congested  (Fig.  203).  They 
consist  of  capillary  hemorrhages  into  the  intraglandular  tissue. 
Erosion  of  the  superficial  layers  of  mucous  membrane  is  usually 
associated. 

There  is  moderate  injection  of  the  mucous  membrane  and  but 
little  thickening  of  the  submucosa.  These  lesions  ma)-  be  seen  in  an>- 
part  of  the  affected  gut,  and  chiefly  in  the  acute  cases. 

2.  Ulceration  {type  of  Harris),  rarer  than  the  classic  type,  and 
believed  to  be  intermediate  between  the  petechiae  and  ''under- 
mined" ulcer.  They  are  probably  the  result  of  the  superficial  ero- 
sions, and  are  primarily  confined  to  the  mucous  membrane,  though 
they  reach  into  the  submucosa  or  to  the  circular  muscle,  but  no 
deeper  (Fig.  204).  They  spread  laterally.  The  ulcer  has  a  punched- 
out  appearance  and  is  round  or  oval,  the  edges  thick  and  congested. 
Base  is  clean,  gray,  and  edematous.     They  often  lie  at  the  apex  of 


506  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

the  intestinal  fold  and  tend  to  increase  in  the  direction  of  the  short 
axis  of  the  bowel,  and  are  found  in  all  regions,  but  less  often  in  the 
advanced  or  chronic  cases.     They  are  most  common  in  the  ileum. 

3.  Classic  or  Undermined  Ulcers. — In  the  early  stage  they  appear 
as  minute  yellow  or  gray  spots  in  the  mucosa,  at  times  at  the  centers 
of  the  "Rogers'  red  dots, "  and  are  usually  surrounded  by  a  congested 
area.  These  spots  are  the  mouths  of  passages  leading  to  cavities 
in  the  submucosa;  the  mouths  and  cavities  are  filled  with  necrotic 
material. 


Fig.  204. — Early  iry:estinal  lesion.  Shows  superficial  necrosis,  glandular  dis- 
tortion, and  round-cell  infiltration.  Borrel's  stain.  Zeiss  obj.  A,  A,  oc.  comp. 
4;  bellows  at  30  cm.  (Woolley  and  Musgrave). 

As  the  ulcerative  process  extends,  the  cavity  in  the  submucosa 
is  enlarged,  and  though  the  necrobiosis  eventually  involves  all  the 
coats,  the  muscular  layers  and  mucosa  are  affected  less  rapidly,  and 
the  latter  may  he  markedly  undermined.  The  ulcers  may  gradually 
coalesce  on  the  surface,  or  quite  frequently  the  cavities  in  the  sub- 
mucosa may  communicate  with  each  other  by  tunnels,  while  the 
mucous  membrane  shows  a  catarrhal  condition.  The  submucosa 
becomes  thickened  and  edematous,  as  do  often  the  muscular  layers 
and  peritoneal  coat   (Fig.  205). 

The  ulcers  may  be  from  the  size  of  a  pin-head  to  the  palm  of  the 


DYSENTERY 


507 


hand.  In  extensive  ulceration  the  muscular  layer  may  become 
necrosed  or  even  perforated,  and  the  base  of  the  ulcer  be  formed  by 
peritoneum  or  omentum.  The  omentum  plays  an  important  pro- 
tective part,  being  frequently,  early  in  the  ulcerative  stage,  found 
adherent  to  the  surface  of  the  intestines.  Localized  suppuration  is, 
therefore,   common.     Ulcers  may   perforate  into  the  subperitoneal 


Fig.  205. — Colon.  A  moderately  thick- 
ened gut  with  various  types  of  ulcers 
(Woolley  and  Musgrave). 


Fig.  206. — Colon.  Thin-walled  gut, 
with  shallow  ulcers,  some  slightly 
undermined,  others  punched  out 
(Woolley  and  Musgrave). 


or  retroperitoneal  tissue.  They  are  usually  circumscribed,  though 
they  may  burrow  (Fig.  206). 

Healing  Process. — In  the  case  of  the  small  ulcers  there  may  be 
complete  repair,  the  epithelium  from  the  mucous  membrane  lining 
the  ulcer,  except  its  base.  In  larger  ulcers  there  may  be  considerable 
scar  tissue,  which  may  lead  to  contraction. 

According  to  Musgrave 's  obser\'ation  there  is  established  in  cases 


508  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

of  long  duration  not  systematically  treated  a  chronic  catarrJial 
condition  with  subsequent  atrophy  (enteritis  chronica  atrophicans), 
a  thinness  of  the  bowel,  absence  of  normal  folds,  atrophy  of  the 
mucosa  and  increased  length;  and  he  places  it  in  the  classification 
of  sprue  or  psilosis,  believing  untreated  amebiosis  to  be  one  of  the 
causes  of  this  condition.  There  may  be,  on  the  other  hand,  in  some 
cases  localized  hypertrophy  with  well-developed  polypi. 

Location  of  the  Lesions. — Harris  believes  that  in  fully  one-half  the 
cases  the  lesions  do  not  extend  beyond  the  beginning  of  the  transverse 
colon;  while  Rogers  holds  that  they  are  more  frequently  limited  to 
the  cecum  and  ascending  colon.     The  ileum  just  above  the  ileocecal 


Fig.    207. — Amebae    in    a   blood-vessel;    X500.    Heidenhain    iron    hematoxylin 
(Woolley  and  Musgrave). 

valve  is  rarely  involved,  and  generally  by  only  a  few  ulcers  (super- 
ficial) and  a  slight  involvement  if  diphtheritic  inflammation  compli- 
cates.     The  lower  rectum  is  rarely  involved. 

Strong  and  ]\Iusgrave,  comparing  200  cases  treated  and  untreated, 
find  159  cases  involve  the  entire  large  bowel,  excepting  the  lower  rec- 
tum; 23,  the  cecum  and  ascending  colon;  2,  the  transverse  colon;  the 
descending  colon,  sigmoid,  and  rectum,  9;  unrecorded,  7;  appendix 
ulcerated,  2  (amebic);  with  large  intestine,  14;  ileum  with  large 
intestine,  7. 

The  presence  or  absence  of  irrigation  treatment  makes  a  differ- 
ence.    In  cases  dying  early  from  intermittent  disease,  ulceration  in 


DYSENTERY  509 

the  cecum  and  ascending  colon,  1 1 ;  in  descending  colon,    sigmoid, 
and  rectum,  8 ;  in  the  entire  bowel,  6. 

Microscopic. — Mucous  membrane  between  the  ulcers  is  little 
changed.  In  the  neighborhood  of  the  lesions  a  tendency  to  hyper- 
trophy with  mucoid  degeneration  and  cyst  formation.  In  the  early 
lesions,  congestion  with  capillary  hemorrhages  and  edema  of  the 
mucosa;  increase  of  lymphoid  cells  in  the  interglandular  tissue. 

Ameba  from  4  to  35/2  long  are  present  in  the  glands,  inter- 
glandular tissues  and  blood-vessels,  muscularis  mucosa,  and  in  the 
veins  of  the  submucosa  (Fig.  207). 

In  the  more  advanced  condition  there  is  necrobiosis  (coagula- 
tion necrosis)  in  the  ulcers,  with  lymphoid  infiltration,  congestion 
and  thrombosis,  and  very  little  polymorpholeukocytic  invasion. 
The  amebse  secretion  and  thrombosis  both  tend  to  produce  the 
necrobiosis. 

If  there  is  marked  polymorphonuclear  infiltration,  pathogenic 
bacteria  are  playing  an  active  part  in  the  process;  noticeably  then 
there  is  diphtheritic  inflammation  (Fig.  208)  or  gangrene.  When 
amebae  are  found  in  exudates  rich  in  bacteria,  they  show  evidences 
of  active  phagocytosis.  In  some  cases  there  are  many  bacteria,  but 
they  are  probably  non-pathogenic,  as  marked  leukocytosis  was  not 
present  and  no  process  could  be  seen  to  be  attributed  to  them. 

"  In  effect,  intestinal  amebiosis  may  be  said  to  be  rather  a  subacute 
chronic  inflammatory  process,  as  was  demonstrated  by  the  character 
of  the  exudate  and  infiltration,  by  the  early  formation  of  granulation 
tissue  and  by  the  absence  of  leukocytic  infiltration,  a  notable  absence 
of  purulent  inflamination.  This  applies  to  the  cases  not  complicated 
by  diphtheritic  process  or  gangrene"  (Musgrave). 

If  the  diphtheritic  process  is  associated,  some  strain  of  the  bacil- 
lary  type  is  probably  responsible ;  and  if  gangrene,  some  other  bacteria 
(mixed  infection). 

Lesions  (Abscesses)  of  the  Liver. — There  may  be  local  necroses  of 
the  parenchyma  scattered  throughout  this  organ  due  to  probable 
chemic  products  of  the  am.ebae,  and  also  abscesses. 

_  This  is  quite  a  common  complication  of  amebic  dysentery,  and 
occurred  in  27  out  of  Osier's  119  cases. 

Most  of  the  so-called  amebic  liver  abscesses  are  really  local  necroses 
and  no  pus  at  all.  They  may  be  single  or  multiple ;  when  single,  the 
right  lobe  is  most  commonly  affected  on  the  convex  surface  hear  the 
attachment  to  the  diaphragm,  or  on  the  concave  surface  near  the  bowel* 

Multiple  abscesses  (small  and  superficial)  miliary,  containing 
amebae,  may  be  scattered  throughout  the  liver  substance  (Osier). 

The  hepatic  abscess,  though  it  often  occurs  within  the  first  two 
to  three  months  after  the  onset  of  the  dysentery,  in  some  cases  may 
not  appear  for  several  years.  Some  cases  are  reported  as  occurring 
when  no  dysenteric  symptoms  had  apparently  been  complained  of  by 
the  patient. 


5IO  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

In  the  early  stage -the  abscesses  are  a  grayish-yellow  color,  sharply- 
defined  in  shape,  and  contain  a  spongy  necrotic  material,  with  more  or 
less  glairy  semitransparent  fluid  in  the  interstices.  The  larger  ab- 
scesses have  ragged  necrotic  walls  and  contain  a  viscid  greenish- 
yellow  or  reddish-yellow  purulent  appearing  material,  mixed  with 
blood  and  shreds  of  liver  tissue. 

Old  abscesses  of  a  chronic  type  have  a  dense  fibrous  wall.  The 
outer  zone  is  hyperemic ;  the  midzone  shows  proliferations  of  connec- 
tive-tissue cells,  compression  and  atrophy  of  the  .liver  cells,  and  an 
inner  necrotic  zone.  There  is  the  same  absence  of  true  purulent 
inflammation  as  in  the  intestines,  except  where  there  is  a  secondary 
infection  with  pyogenic  organisms.  When  the  latter  are  present 
we  have  true  purulent  accumulations. 

The  contents  of  the  necrotic  type  of  abscess  show  fatty  and 
glandular  detritus,  necrotic  hepatic  cells,  amebae,  and  occasionally 
Charcot- Ley  den  crystals.  Amebae  are  also  found  in  the  abscess 
walls.     Cultures  are  frequently  sterile. 

Micrococci  and  bacilH  may  be  found,  notably  the  Staphylococcus 
aureus.  Streptococcus  pyogenes.  Bacillus  coli  (with  other  organisms), 
Bacillus  pyocyaneus,  and  Micrococcus  lanceolatus. 

The  abscess  most  frequently  points  upward  and  ruptures  into  the 
right  lung.  In  some  cases  an  empyema  may  be  produced  or  a  pyo- 
pneumothorax. Perforation  may  occur  in  other  directions,  into  the 
pericardium,  peritoneum,  stomach,  intestines,  portal  or  hepatic  veins, 
inferior  vena  cava,  kidney,  or  externally. 

Symptoms. ^There  has  been  a  tendency  to  arbitrarily  divide 
amebic  dysentery  into  two  clinical  types,  the  acute  and  the  chronic, 
and  to  create  the  impression  that  in  acute  and  chronic  dysentery 
we  have  necessarily  diarrhea  or  diarrhea  alternating  with  constipa- 
tion, the  passage  of  blood  and  mucus,  and  the  presence  of  tenesmus. 
Unquestionably  latent  and  masked  infections,  with  intestinal  ame- 
biosis  are  by  no  means  rare,  and  marked  pathologic  changes  may  be 
present  without  objective  clinical  symptoms. 

Councilman,  Lafleur,  Osier,  Dock,  Strong,  and  Musgrave  have 
reported  such  cases.  The  latter  notably  refers  to  one  case  treated  six 
months  for  constipation,  in  whom  autopsy  showed  perforation  of  a 
liver  abscess  as  the  cause  of  death,  with  associated  lesions  (amebic 
ulceration)  of  the  cecum  and  ascending  colon. 

The  early  recognition  of  these  irregular  types  is  of  great  import- 
ance, especially  when  amebic  dysentery  is  endemic.  Unquestionably, 
some  of  our  old  cases  of  apparently  simple  catarrhal  colitis  are  of  this 
type.  In  fact,  I  have  had  one  experience  with  such  a  case,  where 
amebae  were  found  present,  y\dth  ultimate  recovery  under  appropri- 
ate treatment. 

vSince  many  of  the  cases  may  present  no  clinical  symptoms  of 
amebic  dysentery,  I  believe  Musgrave's'  classification,  under  "In- 
1  Journal  of  American  Medical  Association,  September  i6,  1905. 


DYSENTERY  511 

testinal   Amebiasis,"   to   be  the  most  scientific,   which  I  have  but 
sHghtly  modified. 

1.  Latent  and  masked  infections  with  the  amebae. 

2.  Mild  and  moderately  severe  infections  (subacute  dysentery). 

3.  Severe  infection,  including  gangrenous  and  diphtheritic  types 
(acute  dysentery). 

4.  Chronic  dysentery. 

5.  Infection  in  children  and  in  the  aged. 

Latent  Infection. — In  these  cases  there  is  a  pathologic  amebic 
process  in  the  intestines,  without  any  diarrhea  or  any  other  s^'mp- 
toms  that  would  indicate  the  infection. 

Musgrave  has  demonstrated  that  the  symptoms  pointing  to 
dysentery  may  be  absent  for  a  long  time,  yet  there  are  certain  symp- 
toms which  suggest  the  condition. 

Dull  aching  abdominal  pains  are  present,  which  are  attributed  to 
catching  cold.  They  first  appear  and  are  most  active  during  the  night 
or  early  morning.  Indigestion,  headache,  lassitude,  coated  tongue, 
and  a  foul  breath  are  present.  There  are  loss  of  appetite,  some  loss 
of  weight,  loss  of  color,  and  at  times  a  yellow  skin. 

Physical  examination  discloses  on  deep  palpation  tenderness 
along  the  colon,  especially  over  the  cecum  and  ascending  colon.  This 
last  is  a  significant  symptom;  occasionally  thickened  intestines  can 
be  made  out.  If  a  hydragogue  cathartic  be  administered,  there  will 
be  present  in  the  stool  amebae,  mucus,  tissue  elements,  and  often  old 
blood. 

Musgrave  has  demonstrated  by  autopsy  on  his  fatal  latent  cases 
that  the  lesions  are  in  the  cecum  and  ascending  colon.  Any  patient, 
therefore,  living  where  amebic  dysentery  is  endemic,  suffering  from 
the  symptoms  referred  to,  should  be  given  a  saline,  and  the  stool 
•carefully  searched  for  amebae.  The  possibility  of  amebic  infection 
in  chronic  coHtis  with  no  diarrhea  should  be  considered  in  New  York. 
I  have  already  referred  to  a  patient  infected  in  that  State.  On  the 
other  hand,  some  of  the  latent  cases,  if  untreated,  may  later  de^'elop 
the  symptoms  of  amebic  dysenter}^ 

-  Under  the  same  class  of  cases  (latent)  in  regions  where  amebiosis 
is  endemic  we  may  have  patients  in  whom  other  symptoms,  such  as 
chronic  constipation,  gastric  symptoms,  or  even  appendicitis,  may 
mask  the  intestinal  amebiosis.     Musgrave  has  reported  such  cases. 

Mild  and  Moderately  Severe  Cases  (Subacute  Dysentery). — Mild 
Cases. — These  frequently  develop  from  the  latent  type  and  often  pre- 
sent the  aspects  of  a  diarrhea  and  not  of  dysentery.  Abdominal  pain, 
tenderness  along  the  colon,  headache,  digestive  disturbances,  irrita- 
bility, melancholic  condition,  anemia,  and  loss  of  weight  are  present. 

Amebae  are  found  in  the  diarrheal  movements.  Some  of  these 
cases  never  show  dysenteric  movements,  even  without  treatment. 
This  type  Musgrave  believes  often  becomes  chronic;  while,  on  the 
other  hand,  chronic  gastro-enteritis  or  "sprue"  may  be  the  ultimate 


512  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

outcome,   giving  their  clinical  pictures.     The  patient  usually  dies 
from  intermittent  disease  or  complications. 

Moderately  Severe  Cases  {Subacute  Dysentery). — In  these  cases 
with  the  symptoms  just  described  there  may  be  a  diarrhea  more 
marked  in  the  morning,  consisting  of  several  semifluid  stools,  no 
mucus  or  blood,  and  passed  without  pain.  This  may  intermit  with 
constipation.  Finally,  the  attack  may  increase  in  intensity,  and 
mucus  and  blood  will  appear.  In  other  cases  they  will  occur  from 
the  onset.  Usually  the  more  acute  the  onset,  the  more  rapidly  the^ 
severe  symptoms  develop. 

Severe  Cases  {Acute  Dysentery). — -These  are  the  classical  cases 
usually  described.  Diphtheritic  and  gangrenous  processes,  due  to 
some  secondary  infection,  are  most  common  in  this  type. 

The  onset  is  usually  quite  sudden,  whether  primary  or  following 
on  a  milder  type.  There  are  marked  abdominal  colic;  diarrhea; 
tenesmus,  which  may  be  constant  and  very  painful;  straining,  and 
then  finally  passages  chiefly  of  small  quantities  of  mucus  and  blood. 
In  some  cases  the  dejecta  are  hemorrhagic,  consisting  of  pure  blood 
or  dark  and  coagulated  blood.  Sloughs  are  passed  in  others,  con- 
sisting of  gray  or  blackish  masses  of  necrotic  tissue  of  very  foul 
odor. 

The  temperature,  as  a  rule,  is  not  high.  The  patient  rapidly 
emaciates,  and  the  heart  becomes  rapid  and  feeble. 

Death  may  occur  in  severe  cases  within  a  week  from  the  onset. 
Hemorrhage  (intestinal)  or  perforative  peritonitis  may  take  place. 
Many  cases  recover,  but  some  become  chronic.  In  others  extensive 
ulceration  may  remain  after  sloughing  and  the  diarrhea  continues, 
the  patient  rapidly  emaciating,  and  finally  dying  exhausted  within 
a  couple  of  months.  Emaciation  is  very  marked  in  these  patients. 
Corneal  ulceration  may  occur. 

Stools. — As  many  as  twenty  to  thirty  may  be  passed  in  twenty- 
four  hours,  colicky  pains  usually  precede  them,  and  they  are  followed 
by  straining  and  severe  tenesmus.  Movements  at  first  are  copious, 
later  scanty,  and  chiefly  mucus  and  blood.  Intermissions  and 
exacerbations  of  diarrhea  occur,  gangrenous  dejecta,  dark  red  brown 
and  containing  gray  or  black  fragments  of  tissue  (foul  in  odor),  may 
be  passed,  or  pure  blood.     Amebse  are  present  in  the  stools. 

Abdominal  Pains. — These  are  quite  severe,  chiefly  before  evacua- 
tion, and  sometimes  continuous.  They  are  frequently  located  in  the 
umbilical  region  and  left  iliac  fossa ;  at  times  in  the  right  iliac  fossa, 
and  may  simulate  appendicitis.     Pressure  increases  the  pain. 

Tenesmus. — ^This  consists  of  pressure  and  constriction  in  the 
rectum  and  a  desire  to  go  to  stool.  It  may  be  continuous  and  accom- 
panied by  dysuria  or  strangury. 

Other  Symptoms. — ^Fever  may  occur,  generally  of  moderate  type, 
and  it  may  be  accompanied  by  chills  at  the  onset.  Temperature  is 
irregular.     Anorexia,    nausea,    and    vomiting    may    occur.     There 


DYSENTERY  513 

may  be  severe  prostration,  cold  extremities,  delirium,  stupor, 
drowsiness,  and  cerebral  disorders. 

Chronic  Dysentery. — This  type  of  dysentery  shows  several  forms. 
It  may  be  rather  mild,  characterized  chiefly  by  diarrhea,  with  no 
blood  or  tenesmus,  following  on  the  mild  type  previously  described. 
This  may  continue  a  number  of  years. 

Dysentery  in  more  marked  cases  is  subacute  from  the  onset 
or  gradually  passes  into  the  chronic  stage.  There  are  generally 
alternating  periods  of  diarrhea  and  constipation  covering  several 
years.  During  the  exacerbations  there  are  pain,  passages  of  blood 
and  mucus,  tenesmus,  and  a  slight  rise  of  temperature.  Many  such 
cases  do  not  feel  especially  ill  between  attacks  and  keep  fairly  well 
nourished.  The  appetite  is  often  irregular  in  this  type,  and  errors 
in  diet  are  followed  by  exacerbations  of  the  disease.  The  tongue  is 
red,  glazed,  and  beefy. 

In  more  severe  cases  emaciation  may  be  extreme  and  the  patient 
be  confined  to  bed  most  of  the  time.  There  are  loss  of  appetite  and 
nausea ;  diarrhea  is  quite  persistent,  there  being  mucus  or  mucus  and 
blood  in  the  stools,  with  attacks  of  colic  and  tenesmus.  There  may 
be  some  periods  of  improvement. 

Infection  in  Children  and  in  the  Aged. — Musgrave  reports  cases 
in  children  from  the  age  of  six  months  to  ten  years  in  the  Philippines. 
Children  seem  to  present  a  natural  immunity,  he  believes,  and  when 
infection  does  occur  it  seems  of  a  mild  type  and  readily  yields  to 
treatment. 

The  symptoms  resemble  those  of  the  mild  type  in  adults.  In  the 
aged  there  also  seems  to  be  a  natural  immunity,  but  when  the  disease 
was  established  it  ran  a  severe  and  rapid  course. 

Liver  abscess  is  infrequent  in  the  very  young  and  aged ;  Musgrave 
notes  it  is  infrequent  in  the  natives. 

The  only  certain  method  of  diagnosis  is  by  microscopic  examina- 
tion of  the  feces  or  discharges  and  finding  the  amebae. 

Other  parasites  are  found  at  times  associated  with  the  amebae, 
such  as  the  trichomomedae,  ova  of  uncinariae,  embryo  strongyloides, 
tenia,  oxyuris,  etc. 

Circulatory  System. — The  pulse  may  be  of  good  quality  at  first; 
later,  rapid  and  feeble.  There  are  the  changes  of  secondary  anemia. 
Early,  the  blood  is  normal;  later,  the  red  cells  are  those  of  anemia. 
Still  later,  they  may  become  irregular  in  size  and  shape  and  the 
count  be  reduced. 

Leukocytes. — An  increase  in  polynuclears  and  eosinophiles. 
Hemoglobin  decreases  with  the  red  cells.  Spleen  usually  not 
enlarged. 

Temperature  may  be  absent,  moderate,  or  intermittent.  In  cases 
that  are  complicated,  especially  if  there  is  diphtheritic  inflammation 
of  the  colon,  it  may  become  quite  high.  With  liver  abscess  tem- 
perature is  frequent,  but  not  constant.  If  there  is  mixed  infection 
33 


514  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

in  the  liver,  bacteria  with  the  amebae,  the  temperature  may  be 
intermittent  or  remittent  and  resemble  malaria  or  endocarditis. 
Sometimes  it  may  be  subnormal. 

Nervous  System. — Neuritis  and  neuralgias  may  be  present. 

Pain. — This  varies  in  type  and  intensity. 

Tenesmus. — More  often  is  an  indication  of  secondary  involvement 
or  complications.  It  is  never  present  in  the  latent  forms,  and  is 
often  absent  or  very  slight  in  the  moderately  se\'ere  cases. 

In  acute  cases  with  diphtheritic  process  or  secondary  infection, 
as  from  Bacillus  dysenterise  (Shiga),  it  may  be  severe.  It  is  more 
likely  absent  when  the  lesions  are  in  the  cecum  or  upper  colon. 

Colicky  pains  frequently  occur,  and  at  times  severe  colic. 

The  dull,  aching  abdominal  pain  is  often  prodromic  and  persists 
during  the  course  of  the  disease,  at  times  interfering  with  the  patient's 
rest.  The  greatest  intensity  is  usually  along  the  colon,  as  demon- 
strated by  palpation.  Sometimes  it  is  confined  to  the  cecum.  It 
ma}^  be  complained  of  in  the  back.  It  is  probably  due  to  the  ulcera- 
tive process  in  the  bowel  and,  as  demonstrated  in  the  latent  cases, 
as  shown  by  post  mortem,  is  the  only  indication  during  life  of  serious 
lesions.     These  pains  are  often  the  worst  at  night. 

Burning  pains  ("heart-burn  in  the  abdomen")  ^lusgrave  states 
may  be  general  or  local ;  when  the  disease  is  in  the  sigmoid  or  rectum, 
these  pains  may  be  intense,  and  extend  down  the  backs  of  the  thighs 
to  the  calves,  and  old  cases  of  sciatica  may  be  started  up.  Musgrave 
holds  that  the  beginning  of  sciatica,  associated  with  such  cases,  is 
of  sufficiently  frequent  occurrence  to  be  suggestive. 

Appendicitis  pains  are  at  times  stimulated,  but  examination  will 
show  that  the  tenderness  is  located  in  the  caput  coli.  The  differential 
method  by  IMorris'  point  would  be  of  value  in  these  cases,  as  described 
under  Appendicitis. 

Neuralgia,  myalgia'  and  arthralgia  may  be  present.  There  is 
persistent  dull  headache  in  the  back  of  the  head  and  neck. 

The  genito-urinary,  respiratory,  and  special  senses  are  rarely 
involved,  as  is  also  true  of  the  joints  and  osseous  systems,  though 
complications  may  occur. 

Diagnosis. — In  amebic  dysentery  there  are  so  many  clinical 
tvpes  that  the  diagnosis  is  by  no  means  easy,  and  can  only  be  made 
absolutely  by  microscopic  examination  of  the  feces. 

In  regions  where  the  disease  is  endemic  and  the  microscope  is  not 
available  one  can  reasonably  infer  its  presence  by  the  most  valuable 
symptom,  to  which  I  have  already  alluded,  namely,  "abdominal 
soreness  which  is  increased  on  pressure  and  extends  along  the  course 
of  the  colon,  especially  when  there  is  maximum  intensity  over  the 
cecum  and  ascending  colon." 

If  bowel  movements  are  present,  their  odor  and  the  appearance 
of  blood  are  of  chief  diagnostic  import.  Indigestion,  pain,  nausea, 
and  other  symptoms  are  not  as  important. 


DYSENTERY  §15, 

Often  a  thickened  tender  colon  may  be  felt  on  palpation.  These 
symptoms  give  the  nearest  approach  to  diagnosis  without  micro- 
scopic examination  of  the  feces.  Loss  of  weight  is  a  guide  to  the 
infection. 

Musgrave  believes  that  the  presence  of  ameba  in  the  stools  in 
tropical  regions  should  be  considered  diagnostic  for  purposes  of 
treatment. 

Amebiosis  should  be  treated,   even  if  other   complications  are 

present. 

Prognosis. — The  disease  is  generally  milder  iri  children  and  in 
the  natives  of  the  tropics.  The  course  is  shorter  and  the  mortality 
higher   among   the   aged.      Previous    good    health   is    a    favorable 

factor. 

The  shorter  the  duration  of  the  disease  and  the  earlier  the  local 
treatment,  the  better  is  the  prognosis. 

The  higher  up  the  lesion,  the  greater  the  mortality  and  the  less 
active  the  clinical  symptoms  of  dysentery.  Infections  of  the  cecum 
are  the  most  serious. 

Under  proper  treatment  recovery  is  the  rule  in  young  and  well- 
nourished  adults  if  the  disease  is  not  of  long  duration.  The  early 
diagnosis  and  treatment  are  the  important  features,  as  otherwise 
the  apparently  mild  cases  may  assume  a  dangerous  character.  Tend- 
ency to  relapse  or  chronicity  are  characteristics.  Abscess  of  the  li\er 
is  a  serious  complication. 

Treatment.— Afet^ica/.— The  disease  is  contracted  probably  in. 
the  same  way  as  typhoid  fever,  and  the  same  prophylactic  measures 
should  be  used.  Infection  through  the  drinking-water  is  undoubtedly 
the  chief  method. 

Musgrave  holds  that  the  best  rule  to  observe  in  countries  where 
the  disease  is  endemic  is  to  "take  nothing  into  the. gastro-intestinal 
tract  which  has  not  been  sterilized."  He  has  found  the  amebae  in 
the  drinking-water ;  on  dishes  washed  in  tap-water ;  in  the  soil  from 
contamination;  on  the  surface  of  uncooked  vegetables,  such  as 
lettuce;  on  raw  fruits;  from  hand  contamination;  and  in  ice-cream, 
water-ices,  and  milk. 

Prophylaxis,  when  the  disease  is  endemic  or  during  epidemics, 

is  very  important. 

All  drinking-water  should  be  boiled,  and  dishes  should  be  washed 
in  boiled  water,  also  the  hands. 

Raw  fruits  and  vegetables  should  first  be  placed  on  ice,  and  then 
have  scalding  water  poured  over  them,  which  kills  the  ameba?. 
Ice-cream  and  water-ices  should  not  be  taken. 

The  vaginal  douche  and  especially  rectal  enemata  from  tap-water 
should  be  avoided. 

The  stools  should  be  disinfected  in  carbolic  acid  (1:20)  or  m 
bichlorid  of  mercury  (i :  1000),  and  the  same  precautions  taken  with 
linen— soaked  in  carbolic  acid  (1:20)  and  boiled. 


5l6  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Care  of  the  hands  and  the  prevention  of  fly  infection  (by  screens) 
are  necessary. 

We  have  aheady  noted  that  mixed  infection  with  the  Bacillus 
dysenteriae  (Shiga)  may  be  present. 

The  acid  of  the  stomach  lessens  the  chance  of  infection,  and  acid 
mixtures  may  be  given,  such  as  dilute  hydrochloric  acid. 

In  acute  dysentery  the  patient  should  be  put  to  bed  and  placed 
on  a  liquid  diet:  barley-water,  rice-water,  bouillon,  broths,  gruels, 
white  of  raw  egg,  tea,  also  peptonized  milk  diluted  with  lime-water 
(at  least  25  per  cent,  or  more),  or  peptonized  and  diluted,  or  equal 
parts  of  milk  and  barley-water.  With  some  sour  milks  agree,  as 
kumyss,  etc. 

Sanatogen  is  an  excellent  preparation  and  somatose  is  of  service. 
Personally  I  prefer  milk-free  diet  and  only  the  strained  broths, 
gruels,  etc.,  and  10  per  cent,  gelatin  solution  flavored  with  vanilla, 
oiv  to  vj  (125-185  cc).  Give  nourishment  in  divided  doses  (2 
quarts  daily)  and  a  large  amount  of  acidulated  water.  If  the  tem- 
perature is  over  102.5  ^-y  only  water  is  given  until  defervescence  to 
that  point.     Later  the  diet  can  be  increased. 

Hot  applications  or  poultices  should  be  employed  over  the 
abdomen  for  the  reUef  of  pain  or  colic. 

Internal  Medication. — Musgrave  and  Osier  both  object  to  the  use 
of  bismuth  preparations  for  the  diarrhea,  on  the  ground  that  they 
coat  the  ulcers  and  interfere  with  their  local  treatment.  I  believe 
this  probably  to  be  true  as  regards  bismuth  subnitrate  or  subcar- 
bonate,  which  would  be  required  in  large  doses.  I  have  occasionally 
employed  bismuth  subgallate,  gr.  5  to  10  (0.3-0.6)  t.  i.  d.,  in  com- 
bination with  other  remedies,  apparently  with  benefit. 

On  the  other  hand,  I  have  seen  at  times  that,  in  spite  of  all 
treatment,  too  frequent  movements  continue  either  in  the  acute  or 
chronic  cases.  In  such  event  I  have  employed  bismuth  subnitrate 
as  much  as  gr.  90  to  120  (6.0-8.0)  in  divided  doses  in  twenty-four 
hours  with  good  results.  This  is  preferable  to  the  use  of  opiates, 
and  I  only  employ  it  to  avoid  such.  I  have  never  had  nitrate  poison- 
ing from  large  doses  of  bismuth  subnitrate.  It  would  seem  a  more 
likely  occurrence  in  children. 

In  the  initial  stage  the  patient  should  be  given  magnesium  or 
sodium  sulphate,  oj  to  ij  (4.0-8.0),  one  or  two  doses,  so  as  to  thor- 
oughly cleanse  the  bowels.  Calomel,  gr.  5  (0.3),  may  be  given,  or 
a  single  dose  of  castor  oil,  oiss  (45.0). 

In  young  persons  these  remedies  in  smaller  doses. 

Some  recommend  TTLxx  (1.18)  of  laudanum,  followed  in  half  an 
hour  by  gr.  20  to  30  (1.3-2.0)  of  pulv.  ipecac,  after  the  saline  treat- 
ment; but,  like  Musgrave,  I  believe  this  of  no  special  service  in 
these  cases. 

Occasionally  salol,  gr.  3  (0.194),  with  guaiacol  carb.,  gr.  3  (0.194), 
and  gr.  i  (0.065)  of  pulv.  ipecac,  given  several  (three  or  four)  times 


DYSENTERY  517 

a  day,  with  small  doses  of  Dover's  powder,  gr.  2  to  3  (0.13-0. 194), 
have  proved  of  service. 

Strong  has  reported  good  results  in  some  cases  by  giving  inter- 
nally acetozone  (i  :  5000  or  i  :  3000)  in  carbonated  water,  i  to  2 
Hters  (quarts)  in  twenty-four  hours  in  divided  doses. 

I  have  recently  employed  i  liter  (quart)  of  acetozone  (i:  1000), 
given  in  divided  doses  by  mouth  during  the  day  with  good  results. 
Just  before  administering,  the  dose  can  be  flavored  with  orange  juice 
to  make  it  more  palatable. 

Among  valuable  astringent  remedies  are: 

Salicylate  of  guaiacol  (guaiacol-salol),  gr.  5  to  10  (0.3-0.6); 
tannalbin,  gr.  10  (0.6) ;  tannigen,  gr.  10  (0.6) ;  or  tannoguaiaform, 
tannopin,  and  tannocol,  given  in  doses  of  gr.  5  to  10  (0.3-0.6)  three 
or  four  times  a  day. 

Hydrochloric  acid  with  pepsin  or  alone,  or  nitromuriatic  acid  are 
of  value.     Musgrave  recommends  hydrochloric  acid.     Thus: 

I^.     Acidi  hydrochlor.  dil.  |  aa  ^iii  (12  o) 

Comp.  tinct.  cinchona  J <->    J   ■     ■  1 

Aq.  destil q.  s.  oiv  (125.0). — M. 

Sig. —  3  j  to  ij  (4.0-8.0)  in  water  t.  i.  d.  before  food. 

Vomiting  should  be  treated  by  the  methods  described  under 
Acute  Gastritis.  Small  doses  of  Dover's  powder  may  be  required 
for  persistent  diarrhea. 

Local  Treattnent. — ^This  is  of  extreme  importance,  not  only  in  the 
acute  but  also  in  the  latent  and  chronic  cases. 

Extensive  researches  were  conducted  by  J.  B.  Thomas,  reported 
in  Bulletin  32,  Bureau  Government  Laboratory,  Manila,  who  found 
the  following  solutions  destructive  to  ameba  or  inhibiting  their 
growth : 

Acetozone,  i :  1000,  most  destructive  to  amebae,  and  alphozone, 
1 :  1000,  nearly  as  much  so. 

They  destroy  other  bacteria  as  well. 

Protargol  and  argyrol,  i :  500,  were  excellent  antiseptics.  Sul- 
phate of  quinin,  1:500,  preferable  strength,  or  bisulph-quinin ; 
nitrate  silver,  1:2000,  of  service;  thymol,  1:2500,  readily  destroys 
amebge;  also  permanganate  of  potash,  i:  2000,  is  useful. 

Hvdrogen  peroxid  was  recommended  by  Harris  some  years  ago, 
and  I  have  used  it  successfully  for  some  time. 

Cold  water  (under  a  temperature  of  45°  F.)  has  been  highly 
advocated  by  J.  P.  Tuttle  as  destructive  to  the  amebae  and  also 
removing  them  from  the  bowel.  He  sometimes  employs  5  to  10  per 
cent,  hvdrogen  peroxid  in  this  injection,  and  places  the  patients  in 
the  knee-elbow  position  and  has  them  retain  the  injection  for  a 
considerable  time  (one-half  hour). 

A  glass  irrigator,  attached  to  a  colon-tube,  with  the  opening 
preferablv  at  the  end,  can  be  employed;  if  the  ulcers  extend  low 


5l8  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

down  into  the  rectum  or  there  is  extreme  tenesmus,  then  an  ordinary- 
rectal  tip. 

The  foot  of  the  bed  should  be  elevated  12  to  18  inches  and  the 
patient  placed  in  the  Sims  position,  or  the  hips  can  be  elevated  on 
a  pan.  The  patient's  position  should  be  changed  and  he  should  be 
moved  so  the  fluid  will  gravitate  into  the  caput  coli  by  movements 
described  as   "rotation  method"  under  Enteroclysis. 

Musgrave  recommends  the  injection  of  at  least  i  to  2  liters 
(quarts) ,  which  should  be  retained  five  to  fifteen  minutes,  preferably 
the  latter.  At  the  commencement,  if  there  is  much  irritation,  often 
a  smaller  quantity  must  be  used. 

The  knee-elbow  position  advised  by  Tuttle  is  excellent  in  the 
latent  or  chronic  cases,  but  I  would  not  advise  it  in  acute  conditions. 

If  there  is  much  irritation  one  can  precede  the  antiseptic  injection 
one-half  hour  by  a  small  enema  of  normal  saline  solution — Bij  (60.0) 
containing  gr.  |  (0.016)  of  morphin — or  with  tincture  belladonna, 
ITLx  (0.592),  alone  or  together. 

This  should  only  be  done  once  or  twice  in  the  first  twenty-four 
hours  and  not  repeated. 

Musgrave  has  suggested  taking  advantage  of  the  action  of 
reversed  peristalsis  by  giving  occasionally  a  preliminary  enema  of 
a  7  to  8  per  cent,  salt  solution,  about  i  pint  (500  cc),  containing  gr.  I 
(0.016)  morphin,  one-half  hour  before  the  antiseptic  injection. 

He  then  employs  acetozone  (i :  5000  to  i :  3000),  combined  with 
quinin  (i :  1000  to  i :  750),  or  gives  the  injections  alternately,  employ- 
ing one  to  five  enemata  every  twenty-four  hours,  according  to  the 
severity  of  the  case. 

Alphozone,  same  strength,  or  hydrogen  peroxid  (i :  10)  can  be 
substituted. 

We  must  remember  that  quinin  affects  some  cases  badly,  causing 
gastric  symptoms,  vomiting,  and  headache.  It  must  be  omitted 
or  weaker  solutions  given  to  such  patients. 

Quinin  is  much  more  efficacious  in  the  strong  solutions  (i:  1000 
to  even  i :  500).  The  usual  solutions  suggested  are  much  too  weak. 
One  can  take  advantage  at  the  same  time  of  the  cold  injections,  as 
suggested  by  Tuttle,  unless  the  patient  have  an  idiosyncrasy  to  cold 
or  renal  complications.  In  such  event  a  hot  injection  at  120°  F. 
is  of  service. 

An  excellent  method  is  to  alternate,  giving  an  enema  of  acetozone 
(i :  1000),  and  the  next  enema  of  quinin  (i  :  1000  to  1:500),  cold, 
at  50°  to  40°  F. 

If  the  quinin  disagrees,  then  alternate  the  acetozone  or  alphozone 
with  thymol  (i:  2500),  or  protargol  or  argyrol  (1:500).  The  silver 
nitrate  is  at  times  found  irritating  in  the  acute  cases. 

Permanganate  of  potash  ( i :  2000)  is  also  of  service,  or  hydrogen 
peroxid,  oiv  (125.0  cc.)  to  i  liter  (quart). 

The  local  treatment  is  of   chief  importance  to  check  the  lesions 


DYSENTERY  519 

and  prevent  liver  abscess.  In  the  latent  cases  the  bowels  should  be 
opened  freely  with  magnesium  sulphate  and  daily  injections  of  quinin 
and  acetozone  given.  In  cases  of  marked  tenesmus,  where  the  large 
or  even  small  injections  cannot  be  retained,  recurrent  irrigations 
with  the  antiseptic  solutions,  i  or  2  gallons — i  pint  (500  cc.)  being 
kept  in  the  bowels,  with  marked  elevation  of  the  bed  and  the  solu- 
tion of  one-half  strength — are  of  great  service. 

Chronic  Dysentery. — In  the  chronic  cases  the  diet  should  be 
quite  liberal,  but  indigestible  and  rich  food  should  be  avoided. 
Mashed  potatoes,  boiled  rice,  and  constipating  food  are  often  indi- 
cated in  the  diarrheal  cases,  and  the  avoidance  of  fruits  and  green 
vegetables.  Milk,  eggs  (raw),  the  sour  milks,  and  fats  are  of  value. 
Judgment  must  be  used  in  each  case  as  to  what  will  agree,  whether 
liquid,  semisolid,  solid  food,  or  combinations.  Sanatogen  is  of 
value,  and  the  iron  preparations  are  often  indicated.  The  tannic 
acid  preparations,  as  suggested  in  the  acute  cases,  should  be  em- 
ployed. Occasionally  large  doses  of  bismuth  subnitrate  are  neces- 
sar}^  Quinin  and  acetozone  injections  should  always  be  employed; 
and  nitrate  of  silver  (i :  3000  to  i :  2000)  is  of  value,  used  once  or 
twice  a  week  to  heal  the  ulcers.     Change  of  climate  is  valuable. 

In  all  cases  of  fever,  sponging  (alcohol)  is  the  best  method  of 
treatment.  I  deprecate  the  use  of  antipyrectics.  If  heart  stimu- 
lants are  required,  small  doses  of  strychnin,  caffein,  and  spartein,  or 
camphorated  oil  by  hypodermic. 

I  have,  moreover,  a  suggestion  which  I  believe  may  prove  of 
value.  Pififard  and  Tousey  have  demonstrated  that  IMorton's  claims 
regarding  the  production  of  internal  fluorescence  by  the  x-rays  after 
the  administration  of  small  doses  of  fluorescein  or  quinin  are  fal- 
lacious. However,  the  use  of  gr.  |  (0.016)  fluorescein  in  ovj  (200  cc.) 
of  water,^  and  placing  the  patient  in  the  full  electric-light  bath  for 
fifteen  minutes  or  more,  I  believe,  might  prove  of  service  in  latent, 
chronic,  or  even  in  acute  dysentery.  There  is  great  heat  penetration 
from  this  light  bath,  as  has  been  demonstrated  in  rheumatic  and 
other  conditions,  and  necessarily  a  certain  penetration  of  light  rays. 
The  heat,  light,  and  fluorescence  are  destructive  to  amebse. 

Musgrave  demonstrated  that  violet  light,  x-ray  light,  and  fluores- 
cence inhibit  amebic  action. 

Carbonic  Acid  Gas  for  Tenesmus. —  Rose  has  demonstrated  that 
the  injection  of  CO2  into  the  rectum  will  relieve  tenesmus.  It  is 
worthy  of  use  as  an  adjunct  and  can  be  given  by  his  bottle. 

Intestinal  hemorrhage  from  dysenteric  ulcers  should  be  treated 
by  high  injections  of  10  per  cent,  gelatin  or,  preferably,  Tremoliere's 
solution,  or,  rather,  a  modification : 

Tremoliere. — Gelatin,  5  per  cent,  solution,  containing  calcium 
chlorid,  2  per  cent. 

1  The  fluorescein  solution  should  be  given  by  high  enema;  soda  bicarbonate, 
gr.  XV,  should  be  added  before  injection,  and  water,  q.  s.  i  quart  (liter). 


520  DISEASES   OE  THE   STOMACH  AND   INTESTINES 

TremoUere  (Modified). — Calcium  lactate,  gr.  20  (1.3);  gelatin 
(10  per  cent.),  oviij  (500  cc). 

Hot  (120°  F.)  or  cold  (40°  F.)  astringent  injections — oj  (4.0) 
alum  to  I  pint  (500  cc.) — may  be  required.  Avoid  cold  if  there  is 
shock. 

Morphin,  gr.  i  to  ^  (0.008-0.016),  by  hypodermic  at  once;  ernu- 
tin,  TTLv  (0.296),  hypodermically,  or  fluidextract  of  ergot,  oj  (4-0), 
internally;  ice-bag  locally;  calcium  chlorid  or  lactate,  gr.  10  (0.6),  by 
mouth  every  three  hours,  gelatin  solution  (5  per  cent.)  may  also  be 
taken  by  mouth.  Hypodermoclysis  may  be  required  if  there  is 
marked  shock,  or  even  infusion. 

"  Surgical  Treatment. — In  cases  of  chronic  dysentery  of  long  dura- 
tion which  do  not  respond  to  medical  treatment,  or  in  such  cases  with 
repeated  acute  exacerbations,  surgical  procedure  is  indicated.  This 
is  true  of  either  the  amebic  or  bacillary  type  of  dysentery. 

"  Appendicostomy. — This  operation  was  first  suggested  by  Weir. 
It  consists  in  suture  of  the  appendix  to  the  abdominal  wall  and  skin, 
and  removal  of  its  apex.  Subsequent  irrigations  of  the  large  in- 
testine are  carried  out  by  means  of  a  small  tube  or  catheter,  which  is 
inserted  through  the  lumen  of  the  appendix. 

"Cecostomy. — An  incision  is  made  over  the  cecum  and  the  latter 
brought  into  the  abdominal  wound.  The  cecum  is  incised  and  sutured 
to  the  abdominal  wall.  A  catheter  or  drainage-tube  is  then  inserted 
for  the  purpose  of  irrigation  of  the  colon.  Gibson  has  devised  a 
valve  operation,  separating  the  abdominal  muscles  in  a  special  manner 
so  as  to  prevent  leakage  and  ultimately  secure  a  more  ready  healing. 
Cecostomy  is  indicated  when  the  appendix  is  diseased  or  in  an  ab- 
normal position,  so  that  appendicostomy  is  impossible. 

'  '5.  G.  Gant's  Modified  Cecostomy. — Gant^  makes  his  incision  over 
the  cecum  nearer  the  ileocecal  junction.  After  opening  the  cecum 
and  suturing  it  to  the  abdominal  wall  by  means  of  a  special  director, 
he  inserts  a  drainage-tube  or  catheter  through  the  ileocecal  valve 
into  the  ileum.  A  second  tube  is  inserted  into  the  cecum.  In  cases 
where  ulceration  of  the  ileum  is  present,  it  is  thus  possible  to  irrigate 
both  ileum  and  colon." 

Excellent  results  have  been  reported  from  these  methods. 

BACILLARY   DYSENTERY 

Definition. — A  form  of  coUtis,  frequently  an  ileocolitis,  usually 
of  an  acute  type;  occurring  sporadically  and  in  severe  epidemics; 
attacking  children  as  well  as  adults,  and  characterized  by  pain, 
tenesmus,  and  the  frequent  passage  of  blood  and  mucus;  the  result 
of  infection  by  a  specific  bacillus,  of  which  there  are  various  strains. 

Etiology. — Owing  to  improvement  in  sanitary  conditions 
bacillary   dysentery  is  less  frequent.     This  is  the  type  which  has 

'  New  York  Med.  Jour.,  Aug.  15,  1908. 


DYSENTERY  521 

proved  such  a  scourge,  as  epidemics  in  crowded  asylums,  institutions, 
and  camps.  It  is  one  of  the  great  camp  diseases,  and  I  have  aheady 
referred  to  the  fact  that  Woodward  collected  259,071  acute  cases 
during  the  Civil  War.  The  disease  prevails  in  the  Phihppines,  Porto 
Rico,  Cuba,  and  in  South  Africa.  In  Japan  a  fatal  type  has  prevailed, 
especially  in  summer  and  autumn,  having  a  mortality  of  over  25  per 
cent.  In  1899  there  were  125,489  cases  with  26,709  deaths,  collected 
by  Eldridge.  Most  of  the  severe  epidemics  in  the  tropics  are  of  the 
bacillary  type,  and  the  same  form  prevails  in  the  temperate  climates. 

Bacillus  Dysenterice. — In  1892  Ogata,  during  an  epidemic  of 
dysentery  in  Japan,  isolated  fine  bacilli  which  when  introduced  by 
the  mouth  or  rectum  produced  ulceration  in  the  intestines  of  cats. 
In  1897,  during  a  severe  epidemic,  Shiga  isolated  the  Bacillus  dysen- 
teriae  and  described  its  special  characteristics,  demonstrating  it  to 
be  the  specific  cause  of  the  disease.  Flexner  and  Barker  found  in  the 
dysentery  in  the  Philippines  an  identical  organism,  and  Strong, 
Musgrave,  and  Craig  have  made  a  careful  study  of  it. 

It  has  been  found  in  acute  dysentery  in  Porto  Rico.  Out  of  1328 
cases  of  dysentery  in  Manila,  Strong  and  Musgrave  report  71  of  the 
bacillary  type,  51  suspected  bacillary,  and  561  amebic. 

'  Kruse,  in  Germany,  has  isolated  an  identical  bacillus.  Vedder 
and  Duval  demonstrated  that  sporadic  cases  in  adults  in  Philadelphia, 
and  also  epidemics  in  the  Lancaster  County  Asylum,  Pennsylvania, 
and  in  the  Almshouse,  New  Haven,  were  due  to  the  Bacillus  dysen- 
teriae.  Duval  and  Bassett,  during  the  summer  of  1902  at  Mount 
Wilson  Sanitarium,  first  demonstrated  that  certain  forms  of  summer 
diarrhea  in  infants  were  due  to  Bacillus  dysenteriae,  and  under  Flexner 's 
direction  at  the  Rockefeller  Institute  investigation,  into  the  cause  of 
infantile  diarrhea  in  New  York,  Boston,  Philadelphia,  and  Baltimore, 
showed  the  Bacillus  dysenteriae  present  in  63  per  cent,  out  of  412  cases. 

Several  strains  of  this  bacillus  have  been  found,  and  the  Flexner- 
Harris  type  is  the  one  most  frequent  in  the  United  States.  These 
strains  have  been  determined  by  the  relative  agglutinative  power 
of  immune  serum  upon  the  bacilli  isolated,  and  also  by  the  action  of 
the  bacilli  upon  various  sugars.     Flexner  recognizes  three  types  :^ 

1.  "Shiga  type"  attacks  glucose,  without  action  on  other  sugars, 
including  mannite  and  lactose. 

2.  "Flexner-Harris  type"  attacks  glucose,  mannite,  and  dextrin, 
not  lactose. 

3.  "Bacillus"  (Hiss  and  Russell)  attacks  glucose  and  mannite. 
No  action  on  dextrin  and  lactose. 

The  lesions  produced  by  the  diflferent  strains  are  identical. 
The  organism  agglutinates  with  the  blood-serum  of  cases  with  acute 
dysentery,  as  well  as  with  the  serum  of  immunized  animals.  The 
Flexner-Harris  type  agglutinates  in  dilutions  of  i  :  1000  to  i  :  1500. 

1  Hiss  now  recognizes  four  groups  based  on  fermentative  characteristics,  and 
Shiga  has  added  a  fifth,  intermediate  between  the  acid  and  non-acid  bacilli. 


522  DISEASES    OF   THE   STOMACH   AND   INTESTINES 

In  two  instances  the  organism  has  been  isolated  by  Duval  in  the 
stools  of  healthy  children.  In  dysenteric  stools  it  is  most  readily 
isolated  from  the  particles  of  mucus.  The  organism  has  not  yet  been 
isolated  outside  the  human  body,  but  the  belief  is  that  it  is  prob- 
ably water-borne,  and  that  the  same  prophylactic  measures  should 
be  taken  as  in  typhoid  fever.  Camp  epidemics  clearly  originate 
in  this  way,  and  the  care  taken  by  the  Japanese  in  regard  to  the 
latrines  and  water-supply  practically  eliminated  the  disease  during 
their  recent  war. 

Morbid  Anatomy. — In  acute  cases,  when  death  has  occurred 
during  the  first  week,  the  mucous  membrane  of  the  large  intestine  is 
swollen,  hyperemic,  of  a  deep  red  color,  and  presents  elevated  coarse 
ridges  and  folds.  There  are  ecchymotic  patches  scattered  throughout 
the  swollen  mucosa;  over  the  surface  there  is  usually  a  superficial 
necrotic  la3^er,  which  can  be  brushed  off  lightly  with  the  finger.  This 
may  be  in  patches  or  over  large  areas.  There  is  no  ulceration,  but 
only  the  superficial  general  necrosis  of  the  mucosa.  They  are,  in 
effect,  superficial  erosions  which  give  it  a  worm-eaten  appearance. 
This  superficial  necrotic  layer  is,  in  effect,  a  fine  pseudomembrane. 

The  soHtary  follicles  are  swollen  and  red,  but  their  prominence  is 
obscured  in  the  involvement  of  the  mucosa. 

In  severe  cases  the  entire  coats  of  the  colon  may  be  stiff  and  thick, 
and  the  mucous  membrane  greatly  increased  in  thickness,  grayish- 
black  in  color,  extensively  necrotic,  and  in  places  gangrenous. 
The  submucosa  is  often  enormously  thickened  and  edematous. 
The  serous  surface  is  often  deeply  injected  and  the  vessels  of  the 
mesentery,  especially  near  the  sigmoid  and  rectum,  may  be  distended. 

The  ileum  for  lo  or  15  cm.'  is  quite  frequently  involved  (which 
is  rare  in  amebic  dysentery),  having  a  deeply  hemorrhagic  mucosa 
with  superficial  necrosis.  Peyer's  patches  and  the  solitary  glands 
may  be  moderately  swollen.  The  specific  bacilli  and  various  cocci^ 
are  abundant  in  the  necrotic  mucous  membrane,  and  are  said  by 
Strong  to  be  seen  in  all  the  coats. 

In  the  subacute  cases  there  is  less  thickening  of  the  intestinal  walls, 
there  is  less  necrosis,  the  solitary  follicles  are  more  swollen,  the  mucosa 
less  red,  there  are  superficial  erosions,  and  no  ulcers.  The  disease,  as 
suggested  by  the  compHcations,  is  evidently  characterized  by  a  more 
or  less  acute  general  toxemia^  starting  from  a  localized  process. 

Symptoms. — The  incubation  period  is  not  more  than  forty-eight 
hours.  The  onset  is  usually  sudden  and  characterized  by  fever, 
pain  in  the  abdomen,  and  frequent  stools,  first  containing  mucus, 
and  later  consisting  chiefly  of  mucus  and  blood.  The  movements 
increase  in  frequency  and  are  associated  with  tenesmus,  which  be- 

^  Streptococci  and  various  other  types  may  be  present. 

2  The  toxins  of  dysentery  are  probably  excreted  by  the  bile  and  also  through 
the  intestinal  mucosa,  thus  aiding  in  the  damage  to  the  intestines.  Probably  the 
toxins  are  responsible  for  cerebrospinal  lesions  (HerterV 


DYSENTERY  523 

comes  very  marked.  The  movements  may  occur  as  frequent!}'  as 
every  half-hour,  and  there  is  much  straining.  The  tongue  is  coated 
with  a  white  fur  and  there  is  excessive  thirst;  nausea  and  vomiting 
may  occur.  The  abdomen  is  not  distended,  but  there  may  be  tender- 
ness, especially  over  the  colon.  There  are  cramp-like  pains  in  the 
abdomen.  The  spleen  is  not  usually  enlarged.  The  temperature 
rises  to  103°  or  104°  F.  It  may  run  an  irregular  course  and  rise  or 
fall  before  death.  The  pulse  increases  in  rapidity  (100  to  120  or 
even  to  150)  and  becomes  rapid  and  feeble.  Urine  is  decreased  and 
may  contain  albumin.  Liver  not  enlarged  and  no  liver  abscess; 
moderate  leukocytosis  may  be  present.  In  very  acute  cases  the 
patient  becomes  seriously  ill  within  forty-eight  hours,  the  move- 
ments increase  in  frequency,  the  pain  is  of  great  intensity,  severe 
headache,  and  the  patient  becomes  delirious  and  dies  on  the  third 
or  fourth  day.  Lobar  pneumonia,  bronchopneumonia,  acute  bron- 
chitis, and  fib rino purulent  pleuris}^  may  occur. 

In  cases  of  moderate  severity  the  symptoms  abate,  stools  lessen, 
temperature  falls,  and  within  two  or  three  weeks  the  patient  is  con- 
valescent. In  the  subacute  cases  the  attack  may  last  many  weeks 
or  even  months,  the  patients  have  three  to  five  bloody  mucous  stools 
in  twenty-four  hours,  and  become  very  emaciated.  One  of  Strong's 
cases  died  on  the  sixty-fourth  day.  The  Bacillus  dysenteriae  is  found 
in  the  stools  and  agglutinates  with  blood-serum. 

Other  Clinical  Types. — The  description  just  given  applies  to 
the  types  of  bacillary  dysentery  such  as  seen  in  Japan,  the  Philip- 
pines, and  the  tropics,  and  the  features  of  that  in  adults  in  temperate 
climates  differ  in  no  essential,  except  in  many  cases  it  is  less  severe. 

Duval,  as  noted,  has  found  one  of  the  bacillary  dysentery  strains 
in  sporadic  cases  in  Philadelphia  and  elsewhere,  and  the  probability 
is  that  most  cases  of  non-amebic  dysentery  belong  to  this  type. 

The  so-called  acute  catarrhal  dysentery  is  unquestionably  a 
sporadic  form  due  to  the  Bacillus  dysenteriae.  This  is  the  more 
probable  when  we  consider  that  in  ileocolitis  (dysentery)  in  infants 
we  find  a  catarrhal  type.  In  infants  there  are  four  types  of  lesion 
found  on  autopsy  (Holt) : 

FolHcular  ulceration;  catarrhal  inflammation;  catarrhal  inflam- 
mation with  superficial  ulceration;  membranous  inflammation. 

This  last  differs  from  the  membranous  type  in  adults,  in  that 
there  is  little  psuedomembrane  and  no  deep  sloughing.  Holt  has 
well  described  these  varieties. 

Diphtheritic^  dysentery  is  a  type  of  the  bacillary  form  with  great 
necrosis  and  infiltration  of  the  mucosa.  It  is  believed  that  other 
types  of  bacteria  are  also  often  associated  in  the  process. 

1  The  pure  dysentery  bacillus,  unlike  the  typhoid  bacillus,  does  not  lead  to 
bacillemia  or  bacilluria  (Herter,  Bacterial  Infections  of  the  Digestive  Tract).  In 
the  diphtheritic  type,  a  mixed  infection  in  which  streptococci  undoubtedly  are 
prominent,  the  condition  is  unquestionably,  in  my  opinion,  a  general  infection,  as 
shown  by  the  complications. 


524  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

The  secondary  diphtheritic  dysentery  is  a  common  terminal  event 
in  many  acute  and  chronic  diseases.  Vedder  and  Duval  have 
demonstrated  that  the  bacilli  are  present  in  these  cases. 

Peritonitis  is  rare,  either  through  extension  or  by  perforation. 
When  it  occurs  about  the  cecal  region,  perityphlitis  results,  or  when 
low  down,  periproctitis. 

In  io8  cases  collected  by  Woodward,  perforation  occurred  in  ii. 

Abscess  of  the  liver  is  very  rare.  A  few  cases  occurred  in  the 
Civil  or  South  African  War.  In  the  tropics  malaria  and  dysentery 
may  coexist,  and  typhoid  and  dysentery  coexisted  quite  frequently 
in  the  Civil  War.     In  ordinary  practice  it  is  very  rare. 

Complications. — Acute  bronchitis,  pneumonia,  bronchopneu- 
monia, pleurisy,  gangrene  of  the  lung,  albuminuria,  meningitis, 
paralysis,  paraplegia,  in  many  cases  due  to  a  neuritis,  are  not  un- 
common ;  thrombosis  of  cerebral  sinuses,  embolism  (cerebral) ,  rheu- 
matic pains  and  swollen  joints  (analogous  to  gonorrheal  arthritis), 
pericarditis,  endocarditis,  periproctitis,  perityphlitis,  and  occasion- 
ally pyemic  manifestations,  such  as  pylephlebitis  or  abscess  of  the 
spleen,  may  occur.  Anemic  edema  may  be  present  in  protracted 
cases.  Chronic  Bright's  disease  is  an  occasional  sequel  and  intes- 
tinal stricture  is  rare.  Persistent  dyspepsia  and  irritability  of  the 
bowels  may  follow. 

Prognosis.. — -In  the  very  severe  cases  the  prognosis  is  bad,  the 
patient  often  dying  within  one  to  two  weeks.  This  is  especially 
true  in  epidemics.  In  milder  cases  convalescence  begins  by  the  end 
of  the  second  week.  Chronic  cases  may  run  weeks  or  even  months, 
the  patient  becoming  very  emaciated.  They  may  die  at  the  end  of 
several  months.     Convalesence  is  slow  in  any  but  the  mild  cases. 

Treatment. — Prophylaxis. — The  same  precautions  should  be 
exercised  as  regards  boiling  drinking-water,  avoiding  green  vege- 
tables, cleanliness  of  the  hands,  destruction  of  flies,  disinfection  of 
stools  and  linen,  as  are  carried  out  in  amebic  dysentery  and  in 
typhoid  fever. 

Medication. — The  bowels  should  be  at  once  thoroughly  cleared 
with  castor  oil,  oj  to  ij  (30.0-60.0),  or  with  magnesium  sulphate  or 
sodium  sulphate,  5j  to  ij  (4.0-8.0).  Buchanan  has  had  excellent 
results  by  the  sodium  sulphate  treatment;  he  gives  oj  (4.0)  sodium 
sulphate  four  to  even  eight  times  a  day  for  two  to  three  days  until 
blood  and  mucus  have  disappeared.  He  has  treated  855  cases  with 
9  deaths — an  excellent  record. 

The  old  ipecac  treatment  is  still  in  considerable  repute  in  tropical 
countries.  No  food  is  taken  for  three  hours,  then  20  drops  of  lau- 
danum are  administered  and  one-half  hour  later  gr.  20  to  60  (1.3-4.0) 
of  pulv.  ipecac.  If  this  is  vomited,  the  dose  is  repeated  in  a  few 
hours. 

In  South  Africa  the  saline  treatment  was  often  given  combined 
later  with  the  ipecac,  and  Washbourne  reported  good  results. 


DYSENTERY  525 

Ringer  recommends  small  doses  of  bichlorid,  gr.  tco"  (0.00065), 
every  two  to  three  hours,  and  large  doses  of  bismuth  subnitrate  have 
been  used  with  success,  at  least  oss  (2.0)  and  sometimes  as  much 
as  5j  (4.0)  every  two  hours  daily  for  the  first  few  days.  The  fol- 
lowing I  have  found  the  most  rational  method  of  internal  medication.^ 

The  bowels  should  first  be  thoroughly  cleared  by  the  administra- 
tion of  oiss  to  ij  (45.0-60.0)  of  castor  oil  in  the  adult,  or  by  several 
doses  oj  to  ij  (4.0-8.0)  of  magnesia  sulphate  or  sodium  sulphate; 
calomel,  gr.  v  (0.3),  may  precede  this.  A  hot  appHcation  should 
meanwhile  be  applied  to  the  abdomen  to  relieve  the  pain,  and  if  the 
latter  be  unendurable  and  there  is  considerable  collapse,  a  very  small 
hypodermic  of  morphin  may  be  given,  sufficient  to  render  it  endur- 
able and  not  large  enough  to  interfere  with  peristalsis.  It  is  pref- 
erable not  to  administer  opiates  until  thorough  cleansing  of  the 
bowels  has  been  accomplished.  In  fact,  it  is  my  belief  that  opium 
is  given  too  frequently  and  in  too  large  doses,  so  that  material  accu- 
mulates in  the  bowel  which  had  better  be  expelled. 

Bismuth  subnitrate,  which  it  is  preferable,  as  a  rule,  not  to  use  in 
the  undermined  ulcers  of  amebic  dysentery,  in  this  type  is  of  great 
value.  The  dose  should  be  large.  After  thorough  clearing  of  the 
bowels,  bismuth  subnitrate  alone  or  combined  with  equal  parts  of 
saccha  rated  pepsin  should  be  given. 

At  least  gr.  20  to  30  (1.3-2.0)  of  this  mixture  or  even  gr.  20  (2.6) 
of  bismuth  subnitrate  every  two  to  three  hours.  Bismuth  subcarbon^ 
ate,  gr.  10  to  15  (0.6-1.0),  can  be  substituted.  Bismuth  subgallate, 
gr.  5  to  10  (0.3-0.6)  t.  i.  d.,  or  bismuth  salicylate,  gr.  10  (0.6)  t.  i.  d., 
can  be  substituted  in  place  of  some  of  the  usual  doses  of  the  other 
preparations;  thus,  for  example,  bismuth  subgallate  and  bismuth 
subnitrate  could  alternate.  Bismuth  subnitrate,  gr.  30  (2.0),  mis- 
tura  cretae^  5ij  (8.0),  is  an  excellent  combination  in  one  dose,  given 
every  three  or  four  hours.  The  tannin  preparations,  such  as  were 
suggested  in  amebic  dysentery,  can  be  given,  three  doses  substi- 
tuted for  three  of  the  bismuth  in  the  course  of  twenty-four  hours. 
Thus,  if  seven  doses  of  bismuth  were  given  in  twenty-four  hours, 
give  three  of  tannin  and  four  of  bismuth.  If  the  pain  is  severe, 
small  doses  of  opium  may  have  to  be  given,  with  the  precautions 
noted.  Children  should  receive  proportionately  small  doses  of  all 
remedies.     The  opiates  are  described  under  Diarrhea. 

Tenesmus  should  be  relieved  first  by  thorough  bowel  irrigation, 
and  after  this,  if  it  continue,  by  inflation  with  a  small  amount  cf  CO2 
(Rose's  method),  or  by  a  small  injection  of  starch- water  and  lau- 
danum, Tltxv  (0.888),  with  tincture  of  belladonna,  Tllx  (0.59).  Opium 
should  never  be  given  first,  thus  tying  up  the  foul  secretions. 

^  Urotropin,  I  believe,  might  be  of  service;  urotropin,  gr.  v  to  x  (0.3-0.6), 
combined  with  equal  quantities  of  sodium  benzoate,  given  three  or  four  times 
daily.  It  might  lessen  the  toxemia  and  be  of  service  in  the  cases  of  mixed 
infection. 


526  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

Stryclmin,  nitroglycerin,  or  camphorated  oil  by  hypodermic  may 
be  reqmred.  Local  treatment  is  of  paramount  importance.  Zinc, 
sulphocarbolate  of  zinc,  and  silver  nitrate  are  preferable  in  the 
chronic  cases.  Hypodermoclysis,  or  even  infusion,  may  be  required 
in  shock  or  severe  sepsis. 

If  there  is  much  tenesmus,  a  preUminary  suppository  of  bella- 
donna ext.,  gr.  ^  (0.022),  alone  or,  rarely,  combined  with  gr.  ^  (0.008) 
cocain,  or  the  injection  of  gr.  ^  (0.008)  cocain  in  oj  (30.0)  water,  may 
rarely  be  necessary.  The  best  method  is  to  insert  a  recurrent  tube 
and  gently  irrigate  with  normal  saline  solution  at  110°  to  115°  F., 
or  cold  at  40°  to  50°  F.,  and  then,  forcing  the  tube  in  still  further, 
continue  the  antiseptic  irrigation. 

I  have  found  the  recurrent  method  of  irrigation  with  a  double 
tube  (preferably)  or  two  tubes  (soft  catheters)  of  great  value  in  these 
cases,  the  patient's  hips  or  foot  of  the  bed  being  elevated.  The 
patient  is  gradually  accustomed  to  the  fluid,  and  the  quantity  allowed 
to  run  in  before  permitting  return  can  slowly  be  increased  and  there 
is  not  the  endeavor  to  expel  the  solution.  A  single  injection  of  any 
size  can  often  not  be  given. 

On  the  other  hand,  i  to  i  j  Uters  (quarts)  can  be  injected  by  the 
method  of  Musgrave  in  amebic  dysentery  in  some  cases. 

In  the  acute  cases  acetozone,  alphozone,  hydrogen  peroxid,  and 
permanganate  of  potash  are  of  especial  value,  in  the  same  strength 
noted  below  as  employed  in  amebic  dysentery. 

Delafield  has  secured  excellent  results  by  the  use  of  bichlorid  of 
mercury  (1:10,000),  using  2  quarts  (liters),  but  cautiously,  with 
my  recurrent  tube.  I  have  had  good  results  by  this  method,  but 
it  should  never  be  given  by  ordinary  enema. 

Acetozone  (1:1000),  hydrogen  peroxid  (i  :  10),  alphozone  (i : 
1000),  and  permanganate  of  potash  (i :  1000)  are  excellent. 

Mucol,  .5j  (4.0)  to  I  quart  (liter)  or  even  stronger,  has  been 
employed.  This  preparation  contains  the  chlorid,  borate,  bicar- 
bonate, and  benzoate  of  soda,  with  zinc  sulphocarbolate  and  essen- 
tial oils. 

Several  irrigations  or  enemata  may  be  necessary  daily,  depending 
on  the  tenesmus  or  character  of  the  stool,  one  or  two  antiseptic,  and 
the  rest  of  normal  saline  solution,  or  flaxseed  or  gum-arabic. 

If  mucus  and  blood  increase,  a  cathartic  is  again  indicated,  and 
I  believe  it  should  be  given  every  three  days  in  any  event. 

Carbolic  acid  should  never  he  employed  for  irrigation. 

Chronic  Dysentery. — Bismuth  is  of  value.  Nitrate  of  silver  injec- 
tions are  of  ser\'ice — 10  to  30  gr.  (0.6-2.0)  to  i  pint  (500  cc.) — and 
inject  2  to  3  pints  if  possible ;  if  there  is  irritation,  follow  it  with  an 
injection  of  normal  saline  solution. 

Protargol  or  arg\Tol  (i :  500)  are  useful,  and  often  preferable  to 
silver  nitrate. 

Normal  saline  or  normal  saline  with  oil  of  peppermint,  TTlx  (0.59), 


DYSENTERY  527 

can  be  used  between  the  antiseptic  injections,  or  an  injection  of 
flaxseed  tea  or  gum-arabic  solution.     The  latter  are  soothing. 

Diet. — Acute  Cases. — Fluid  diet,  broths,  gruels,  barley-  and 
rice-water,  beef  juice,  sanatogen,  egg-albumen,  and  milk  well  diluted. 
Somatose  is  of  use.     Personally  I  prefer  milk-free  diet. 

In  the  chronic  cases  fruits  and  green  vegetables  should  be  avoided 
and  constipating  food  given  if  there  is  diarrhea.  The  weight  of  the 
patient  should  be  increased  by  administration  of  fats.  The  general 
diet  rules  should  be  similar  to  those  in  amebic  dysentery. 

Serum  Therapy. — Shiga  immunized  horses  and  produced  a  poly- 
valent serum  from  which  he  claims  to  have  reduced  the  mortality 
of  dysentery  in  Japan  from  35  to  9  per  cent. 

Flexner  has  prepared  a  serum,  but  Holt  states  results  in  children 
have  proved  disappointing. 

Complications  should  receive  appropriate  treatment. 


CHAPTER  XXV 

TYPHOID  FEVER 

A  MERE  outline  of  this  disease  will  be  given  for  the  purpose  of  differ- 
ential diagnosis.  Typhoid  may  be  defined  as  a  general  infection  caused 
by  the  Bacillus  typhosus,  characterized  anatomically  by  hyperplasia 
and  ulceration  of  the  intestinal  lymph-follicles,  swelling  of  the  mesen- 
teric glands  and  spleen,  and  by  parenchymatous  changes  in  the  other  or- 
gans, such  as  in  the  kidneys,  liver,  etc.  CHnically  the  disease  is  marked 
by  fever,  rose-colored  eruption,  abdominal  tenderness,  tympanites,  di- 
arrhea, and  splenic  enlargement,  but  these  symptoms  are  inconstant. 

History. — Louis,  in  1829,  gave  the  name  to  the  fever.  Gerhard, 
in  1837,  first  clinically  differentiated  between  typhoid  and  typhus. 

Etiology. — General  prevalence.  It  prevails  in  temperate  cli- 
mates. Imperfect  sewage  and  contamina:ted  water-supply  favor 
the  distribution  of  the  bacilli;  filth,  overcrowding,  and  bad  ventila- 
tion aid  in  lowering  the  resistance  of  the  individual.  Fingers,  food, 
and  flies  spread  the  disease  from  the  infected  person.  It  is  prevalent 
in  England,  Wales,  India,  parts  of  Germany,  and  in  the  United  States, 
where  it  occupies  about  fourth  place  in  the  mortality  list.  It  has 
been  one  of  the  great  scourges  of  armies,  more  destructive  than 
powder  and  shot.  The  mortality  in  the  South  African  and  Spanish- 
American  wars  was  greater  from  typhoid  than  from  bullet  wounds; 
among  the  American  troops,  about  one-fifth  of  the  soldiers  in  the 
national  encampments  had  this  disease.  The  former  inefficiency  of 
our  sanitary  methods  was  a  blot  upon  our  government.  In  great 
contrast  to  this  were  the  remarkable  results  secured  by  the  Japanese 
in  the  recent  Russo-Japanese  War,  where,  in  comparison  with  our  own 
records,  typhoid  and  dysentery  were  practically  negligible  factors. 

Season. — The  disease  is  more  prevalent  in  the  autumn,  though 
frequent  cases  occur  during  August. 

Sex. — Both  sexes  are  equally  liable,  but  males  are  more  frequently 
admitted  to  the  hospitals. 

Age. — ^Typhoid  is  a  disease  of  youth  and  early  adult  life,  the 
greatest  susceptibility  being  between  the  ages  of  fifteen  and  thirty. 
Cases  are  rare  over  sixty.  It  is  not  infrequent  in  children.  Infants 
are  rarely  attacked. 

Immunity. — Not  all  exposed  take  the  disease.  One  attack  usually 
protects;  two  attacks  have  been  described,  and  occasionally  three. 

Bacillus  Typhosus. — The  researches  of  Eberth,  Koch,  and  others 
have  shown  that  the  disease  is  due  to  a  special  micro-organism.  It  is 
a  short,  thick,  flagellated,  motile  bacillus  with  rounded  ends,  in  one 

528 


TYPHOID    FEVER  529 

of  which,  sometimes  in  both,  there  can  be  seen  a  gHstening  round 
body,  probably  an  area  of  degenerate  protoplasm.  It  grows  readily 
on  various  nutritive  media  and  must  be  differentiated  from  the 
Bacillus  coli.^  The  organism  fulfils  all  the  requirements  of  Koch's 
law.  Cultures  are  killed  in  ten  minutes  by  a  temperature  of  60°  C. 
The  direct  rays  of  the  sun  destroy  them  in  from  four  to  ten  hours' 
exposure.  Bouillon  cultures  are  destroyed  by  carbolic  acid  (i :  200) 
and  by  bichlorid  (i :  2500)  solution.  Toxins  have  been  isolated  from 
the  bacilli. 

Distribution  in  the  Body. — The  typhoid  bacilli  may  be  demon- 
strated in  the  circulating  blood,  and  have  been  found  in  the  urine,  stools, 
sweat,  sputum,  and  in  the  rose  spots.  They  occur  in  the  mesenteric 
glands,  spleen,  and  gall-bladder,  and  have  been  found  in  almost  all  the 
organs,  even  in  the  muscles,  uterus,  and  lungs.  Cultures  from  the 
intestines  show  that  few,  and  frequently  none,  can  be  cultivated 
from  the  rectum  up  to  the  cecum.  Above  this  they  are  numerous. 
They  have  been  found  in  the  mucous  membrane  of  the  stomach, 
also  in  the  esophagus,  and  on  the  tongue  and  tonsils,  and  have  been 
isolated  from  endocardial  vegetations,  meningeal  and  pleural  exu- 
dates, and  from  foci  of  suppuration  in  various  parts  of  the  body. 
They  may  be  present  in  the  stools  of  healthy  people  who  have  lived 
in  close  association  with  typhoid  patients. 

Bacilli  Outside  the  Body. — They  retain  their  vitality  for  weeks 
in  water.  This  is  further  demonstrated  from  infection  by  ice,  in 
which  they  exist  for  several  months,  and  live  for  some  days  in  butter 
from  infected  cream.  They  may  live  in  the  upper  layers  of  the  soil 
for  months;  in  street  dust  for  a  month  or  more;  on  linen  for  two 
months;  and  on  Vv^ood  for  a  month. 

Modes  of  Conveyance. — Aerial  transmission  is  not  probable. 
Fingers,  food,  and  flies  are  the  chief  means.  House  infection  is 
difficult  to  avoid  unless  finger  contamination  is  carefully  ehminated. 
Such  epidemics  have  been  reported  at  the  Johns  Hopkins  Hospital. 
Epidemics  have  occurred  from  infection  of  water,  milk,  and  food,^ 
such  as  celery  and  uncooked  vegetables  which  have  grown  in  infected 
soil.  Raw  oysters  are  recorded  as  a  cause  of  epidemics.  Bedbugs  and 
fleas  may  be  carriers.     Water  infection  is  the  most  common  cause. 

Morbid  Anatomy. — Intestines. — A  catarrhal  condition  exists 
throughout  the  large  and  small  intestine.  Specific  changes  occur  in 
the  lymphoid  elements,  chiefly  in  the  lower  end  of  the  ileum.  Four 
stages  are  described : 

I.  Hyperplasia,  involving  Peyer's  patches  in  the  jejunum  and 
ileum  and  to  a  variable  extent  those  in  the  large  intestine.  They 
are  swollen,  grayish  white  in  color,  and  may  project  from  3  to  5 
mm.     The  solitary  glands  may  project  to  a  variable  extent. 

1  Paratyphoid  infection  is  referred  to  under  Diagnosis. 

2  There  is  some  evidence  that  the  digestive  tract  is  not  the  only  portal  of 
infection  for  typhoid  fever,  but  that  the  bacilli  may  enter  by  way  of  the  throat, 
notably  by  the  tonsils  (Herter). 

34 


530  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

There  is  hyperemia  of  the  folHcles;  later  an  increase  and  accu- 
mulation of  the  cells  of  the  lymph-tissue  which  may  infiltrate  the 
adjacent  mucosa  and  muscularis ;  the  blood-vessels  are  compressed, 
which  gives  a  white  anemic  appearance  to  the  follicles. 

This  process  reaches  its  height  from  the  eighth  to  the  tenth  day, 
and  then  undergoes  either  resolution  or  necrosis. 

2.  Necrosis.  When  the  hyperplasia  is  marked,  resolution  is  no 
longer  possible.  The  blood-vessels  become  choked;  there  is  a  con- 
dition of  anemia ;  then  necrosis  and  sloughs  form,  which  must  be  sepa- 
rated and  thrown  off.  This  process  is  always  more  intense  toward 
the  ileocecal  valve.  The  necrosis  is  variable,  it  may  pass  deep  into 
the  muscular  coat,  and  even  perforate  the  peritoneum. 

3.  Ulceration.  Sloughing  is  effected  from  the  edges  inward, 
and  results  in  the  formation  of  an  ulcer,  the  extent  of  which  is 
directly  proportionate  to  the  amount  of  necrosis.  The  muscularis 
usually  forms  the  floor  of  the  ulcer. 

4.  Healing.  The  mucosa  extends  from  the  edge  and  a  new 
growth  of  epithelium  is  formed,  as  are  the  glandular  elements.  The 
healed  ulcer  is  depressed.     Healing  is  never  associated  with  stricture. 

Large  Intestine. — The  cecum  and  colon  are  affected  in  about  one- 
third  of  the  cases,  and  the  solitary  glands  are  sometimes  enlarged. 

Perforation. — About  one-third  of  the  deaths,  Scott's  statistics 
state,  are  due  to  perforation.     It  occurred  in  3.6  per  cent,  of  all  cases. 

The  German  statistics  are  much  lower;  in  Munich  only  5.7  per 
cent,  of  deaths  are  due  to  perforation.  Among  1 500  cases  at  the  Johns 
Hopkins  Hospital  there  were  43  of  perforation ;  20  were  operated  on, 
and  7  of  these  recovered.  The  site  of  the  perforation  is  usually  in 
the  ileum,  within  1 2  inches  of  the  ileocecal  valve.  It  may  be  from 
a  pin-point  to  large  size. 

Death  from  Hemorrhage. — This  occurred  in  12  of  137  deaths  in 
Osier's  1500  cases.     He  could  not  find  the  bleeding  vessels. 

Mesenteric  glands  are  hyperemic  and  swollen.  Necrosis  is 
common;  abscesses  may  occur,  causing  peritonitis  or  hemorrhages. 

Spleen  enlarged,  infarction  not  infrequent.     Rupture  may  occur. 

Bone-marrow. — Same  changes  as  in  lymphoid  tissue,  and  there 
may  be  foci  of  necrosis. 

Liver. — Parenchymatous  degeneration.  Liver  abscess  has  been 
found,  also  acute  yellow  atrophy.     Pylephlebitis  may  occur. 

Gall-bladder. — Acute  cholecystitis  may  be  present. 

Kidneys. — Cloudy  swelling,  with  granular  degeneration;  less 
commonly  an  acute  nephritis;  miliary  abscesses  or  diphtheritic 
inflammation  of  the  pelvis  may  occur ;  also  infection  by  colon  bacilli. 
With  colon  bacilli  infection,  chills,  rise  of  temperature,  and  acute 
renal  S)miptoms  occur  (W.  H.  Thomson). 

Bladder. — Cystitis  or  diphtheritic  inflammation.  Orchitis  and 
acute  mastitis  are  occasionally  met  with. 

Respiratory  Organs. — Ulcer  of  the  larynx;  edema  of  the  glottis; 


TYPHOID    FEVKR 


531 


diphtheritic  inflammation ;  bronchitis ;  pneumonia ;  hypostasis ;  pleu- 
risy; gangrene;  abscess  of  the  lung;  hemorrhagic  infarction  and 
empyema  may  complicate. 

Circulatory  Changes. — Endocarditis,  pericarditis,  and  myocar- 
ditis, endarteritis,  arthritis  of  a  peripheral  vessel  with  thrombus 
formation  may  occur.  Venous  thrombosis  is  more  frequent,  espe- 
cially of  the  left  femoral. 

Nervous  Symptoms. — Meningitis  is  rare ;  optic  neuritis  may  occur ; 
the  cause  of  aphasia  seen  in  children  is  not  positively  known.  Paren- 
chymatous changes  may  occur  in  the  peripheral  nerves. 

Voluntary  Muscles. — ^The  muscular  substance,  especially  of  the 
recti,  pectorals,  and  adductors  of  the  thigh,  may  undergo  granular 
degeneration  or  hyaline  transformation.  Rupture,  hemorrhage, 
or  abscess  have  been  found. 


%^    \9A&..-  DiTlston,  Wari.i Temperatgre  Chart  Vo.Jf.. 


Fig.  209. — Typhoid  chart. 

'  Symptoms.— Incubation,  eight  to  fourteen  days,  occasionally 
to  twenty-three  days,  during  which  period  there  is  lassitude  and 
inaptitude  for  work.  Onset  is  rarely  abrupt,  with  occasional  chills, 
There  may  be  cough  (bronchitis),  epistaxis,  headache,  anorexia, 
diarrhea  in  many  cases,  but  frequently  early  constipation,  abdominal 
pain,  and  distention;  and  in  some  cases  there  is  pain  in  the  right 
iliac  fossa.     At  the  onset  the  patient  usually  takes  to  his  bed. 

During  the  first  week  there  is  in  many  cases  a  steady  rise  of 
temperature,  the  evening  record  rising  a  degree  or  more  each  day, 
and  reaching  103°  to  104°  F.  (Fig.  209).  Variations  of  temperature 
are  common.  It  may  rise  suddenly  to  104°  F.  or  may  fall  suddenly. 
It  may  be  high  a.  m.  and  lower  r.  M. 


532  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

The  pulse  is  rapid,  loo  to  no,  full,  but  of  low  tension,  and  often 
dicrotic.  The  tongue  is  coated  and  white,  the  abdomen  slightly 
distended  and  tender.  Unless  there  is  high  temperature  there  is  no 
delirium.  The  patient  complains  of  headache  and  there  may  be 
mental  confusion  at  night.  The  bowels  are  loose  or  may  be  con- 
stipated. At  the  end  of  the  week  the  spleen  becomes  enlarged  and 
the  eruption  appears  in  the  form  of  rose-colored  spots,  seen  first  on 
the  abdomen.  They  are  raised,  flattened  papules,  can  be  felt  by 
the  finger,  and  disappear  on  pressure.  They  come  out  in  crops  and 
may  appear  on  the  trunk  or  extremities.    Desquamation  may  occur. 

In  the  second  week  the  symptoms  become  aggravated;  the  fever 
remains  high  and  the  morning  remissions  are  slight,  the  pulse  is 
rapid  and  loses  its  dicrotism.  There  are  mental  torpor  and  dulness; 
the  lips  are  dry  and  the  tongue  may  become  dry.  Tympanites, 
tenderness,  and  diarrhea,  if  present,  become  aggravated.  The 
stools  are  described  as  pea-soup.  Death  may  occur  at  the  end  of 
this  week  from  hemorrhage  or  perforation,  but  generally  later.  In 
the  third  week  the  pulse  ranges  from  no  to  130.  The  temperature 
shows  marked  morning  remissions  and  there  is  a  gradual  decline  in 
the  fever.     lyoss  of  flesh  is  more  marked  and  weakness  is  pronounced. 

Diarrhea  and  meteorism  may  in  some  cases  occur  for  the  first 
time.  Unfavorable  symptoms  are  pulmonary  complications,  feeble- 
ness of  the  heart,  delirium  with  muscular  tremor,  and  acute  tym- 
panites. The  tongue  may  become  brown  or  brownish  black  and  the 
lips  and  teeth  be  covered  with  sordes. 

Special  dangers  are  perforation  and  hemorrhage. 

The  fourth  week  convalescence  begins.  Temperature  gradually 
becomes  normal;  diarrhea  stops;  tongue  cleans;  the  desire  for  food 
returns.  In  severe  cases  the  fourth  and  fifth  weeks  present  an 
aggravated  picture  of  the  third,  the  patient  grows  weaker,  pulse 
more  rapid  and  feeble,  tongue  dry,  and  abdomen  distended.  He 
lies  in  profound  stupor  with  low  muttering  delirium  and  subsultus 
tendinum  and  passes  the  feces  and  urine  involuntarily.  Heart 
failure  and  secondary  complications  are  the  chief  dangers. 

In  the  fifth  and  sixth  weeks  protracted  cases  show  irregular 
fever,  and  convalescence  may  not  set  in  until  the  fortieth  day  or 
longer.  During  this  period,  recrudescence  of  temperature  may 
occur  from  errors  in  diet,  constipation,  or  excitement;  or  a  relapse 
(re-infection)  mav  occur.  With  relapse  there  is  a  repetition  of  the 
ascent  of  the  original  fever.  A  rise  in  temperature  from  a  com- 
plication  usually   has    leukocytosis   associated. 

Modes  of  Onset. — As  a  rule,  the  onset  is  insidious.  The  following 
deviations  may  occur:  Marked  nervous  symptoms,  such  as  headache 
or  cerebrospinal  symptoms,  with  retraction  of  the  head  and  convul- 
sions; or  mania;  or  stupor.  Pulmonary  symptoms,  such  as  bron- 
chitis, pneumonia,  or  pleurisy.  Intense  gastro-intestinal  symptoms, 
with  pain  and  vomiting,  suggestive  of  poisoning,  or  in  some  cases 


TYPHOID  fevBr  533 

simulating  appendicitis.  Acute  nephritis  is  the  first  symptom. 
Ambulatory  form,  in  which  the  patient  keeps  about  and  attempts 
to  work.  This  runs  a  severe  course  and  often  a  fatal  issue  results. 
Chills  may  occur  at  the  onset  and  may  be  followed  by  sweats,  and 
they  are  present  with  complications.  Variations  from  the  typic  tem- 
perature are  common,  the  step-like  ascent  does  not  always  occur,  but 
the  fever  may  rise  suddenly.  A  sudden  fall  of  temperature  is  sug- 
gestive of  hemorrhage  before  blood  appears  in  the  stools.  Peliomata, 
maculae  cerulae — pale-blue  or  steel-gray  spots — are  sometimes  present 
due  to  lice.  Erythema  may  occur.  Bed-sores  are  not  uncommon 
and  boils  are  a  troublesome  sequel. 

Blood. — ^Leukopenia  (hypoleukocytosis)  is  present;  lymphocytes 
are  relatively  increased.  Eosinophiles  disappear  or  are  markedly 
diminished.  The  reappearance  or  increase  of  eosinophilia  is  a  good 
prognostic  sign.  Leukopenia  and  absence  of  eosinophiles  aid 
diagnosis.     Hemoglobin  and  red  corpuscles  are  reduced. 

Severe  meteorism  is  a  danger-signal  and  predisposes  to  hemorrhage 
or  perforation.  Acute  gastro-intestinal  dilatation  or  acute  ectasia 
alone  may  occur.  Acute  distention  may  even  simulate  perfora- 
tion; and  it  is  only  possible  to  differentiate  by  relieving  the  dis- 
tention by  enteroclysis  and  lavage. 

Symptoms  of  Perforation. — Sudden  sharp  pain,  at  times  paroxys- 
mal, often  in  the  hypogastric  region  to  the  right  of  the  median  line; 
tenderness,  sudden  distention,  and  muscular  rigidity.  This  last 
is  an  important  symptom.  There  are  shock,  fall  of  temperature, 
pallor,  sweating,  and  the  Hippocratic  facies.  The  temperature  then 
rises,  pulse  rapid  and  feeble,  respiration  increases.  Vomiting  is  often 
present.  Leukocytosis  and  especially  increase  in  the  polynuclears. 
Percussion  may  show  a  flat  note  in  the  flank,  dlie  to  exudate. 
Obliteration  of  liver  flatness  may  be  caused  by  tympany. 

Abscess  of  the  liver  and  cholecystitis  may  complicate.  Gall- 
stones in  many  cases  are  probably  associated  with  the  presence  of 
typhoid  bacilli  in  the  gall-bladder.  Under  Lesions  most  of  the  com- 
plications are  referred  to.     Loss  of  hair  may  occur. 

Local  neuritis,  as  in  the  arms,  legs,  or  toes  (tender  toes),  may 
occur.  Multiple  neuritis  is  a  complication  of  convalescence.  Polio- 
myelitis, tetany,  and  hemiplegia  have  been  reported.  Typhoid 
pyschoses  may  occur,  also  eye  and  ear  complications,  and  retention 
of  urine.     Posttyphoid  anemia  may  be  severe. 

Ehrlich's  Diazo-reaction. — This  test  is  not  absolutely  diagnostic, 
as  it  occurs  in  miliary  tuberculosis,  in  malaria,  and  occasionally  in 
other  acute  disease,  associated  with  high  fever.  It  is  of  accessory 
value  taken  with  other  data.  Bacilluria  occurs  in  about  one-third 
of  the  cases.     Acute  appendicitis  may  complicate. 

Osseous  System. — Periostitis,  osteitis,  caries,  and  necrosis  are  trou- 
blesome sequelae  of  typhoid,  as  are  arthritis  and  typhoid  spine.  Colitis, 
simple  catarrhal  or  of  a  septic  (diphtheritic)  type,  may  complicate. 


534  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

Posttyphoid  septicemia  and  pyemia  are  not  uncommon.  Furun- 
cles, abscesses,  and  infarcts  in  various  regions  may  occur.  With  chil- 
dren typhoid  fever  often  runs  a  mild  and  irregular  course. 

Diagnosis. — The  type  of  temperature,  splenic  enlargement, 
eruption,  absence  of  leukocytosis,  disappearance  of  the  eosinophiles, 
together  with  Ehrlich's  reaction,  are  the  chief  signs.  Isolation  of 
the  typhoid  bacilli  from  the  blood,  stools,  and  urine  is  diagnostic. 
Widal's  reaction  is  of  positive  value  when  foimd.  It  is  generally 
not  in  evidence  until  the  seventh  to  tenth  day,  sometimes  not  until 
convalescence,  and  occasionally  not  at  all.  Cabot  claims  over 
90  per  cent,  reactions  before  the  eighth  day.  Fortunately  it  is 
present  in  about  90  per  cent,  of  cases.  Blood  examination  will  differ- 
entiate between  t3^phoid  and  malaria.  Ulcerative  endocarditis  has 
been  mistaken  for  typhoid,  but  the  presence  of  the  heart  lesion  and 
the  streptococci  in  the  blood  are  diagnostic.  With  acute  miliary 
tuberculosis  the  temperature  is  irregular  or  intermittent.^  Respira- 
tion is  more  rapid  and  there  is  more  cyanosis.  AVidal  is  negative,  but 
leukoc^-tosis  is  common.  With  t^'phoid  we  have  the  Widal  reaction; 
there  is  leukopenia,  splenic  enlargement  is  present,  and  the  typic 
eruption.  Intestinal  grip  may  for  a  few  days  simulate  typhoid,  as 
may  intestinal  toxemia."  The  subsequent  course,  absence  of  AVidal 
reaction,  etc.,  clear  the  diagnosis. 

Prognosis. — Mortality.  Death-rate  is  variable,  depending  on 
the  severity  of  the  epidemic  and  when  treatment  has  begun.  Of 
recent  years  it  has  been  from  5  to  20  per  cent.  Fat  people  stand 
typhoid  badh^  ^leteorism,  hemorrhage,  high  fever,  and  nervous 
symptoms  give  a  bad  prognosis. 

Prophylaxis. — Care  in  drainage  and  water-supply  are  most  im- 
portant. Raw  milk,  raw  oysters,  and  uncooked  fruit  and  vegetables 
should  be  avoided  during  an  epidemic.  Raw  oysters  in  Xew  York 
should  generally  be  avoided,  unless  the  source  of  the  supply  is  known. 
The  urine,  stools,  and  sputum  should  be  disinfected.  The  sputum 
can  be  collected  in  cloths  and  burned,  and  bichlorid  (i :  1000)  or 
carbolic  (i :  20)  used  to  disinfect  the  other  discharges.  About  twice 
the  volume  of  the  disinfectant  should  be  mixed  with  the  stools,  and 
it  should  be  left  to  stand  for  two  hours  before  emptying.  For  dis- 
infection of  the  bath  water,  h  pound  of  chlorid  of  lime  will  render  an 
ordinary  bath  of  200  liters  sterile  in  one-half  hour  (Babucke).  The 
nurse  should  wear  a  rubber  apron  and  should  wash  it  frequently  with 
carbolic  or  bichlorid.  When  giving  baths,  rubber  gloves,  or  espe- 
cially rubber  finger-tips,  should  be  worn,  and  the  hands  thoroughly 
^  Tubercle  bacilli  may  be  found  in  the  fluid  by  lumbar  puncture,  and  there  is 
an  absence  of  typhoid  bacilli  in  the  blood-culture.  The  tuberculin  test  (ocular) 
or  by  injection  is  of  value. 

2  The  paralj'phoid  bacilli  A.  and  B.  may  produce  symptoms  like  a  mild 
typhoid,  and  paratyphoid  B.  may  be  productive  of  meat-poisoning.  The  Bacillus 
faecalis  alcaligenes  and  Bacillus  enteritidis  (Gartner)  may  incite  symptoms  simu- 
lating mild  typhoid  (Herter).  These  bacilli  differ  from  the  typhoid  bacilli  in 
agglutination  reactions,  etc. 


TYPHOID   FEVER  535 

disinfected  later.  All  bedding  and  the  patient's  night  dress  should  be 
soaked  two  hours  in  i :  20  carbolic  and  then  boiled.  A  special  cup, 
dish,  spoon,  etc.,  should  be  used  for  the  patient  and  disinfected  on 
each  occasion  after  using.  It  is  best  to  keep  them  in  the  room  and 
transfer  the  food  from  another  vessel  to  the  special  cup  or  dish ;  if  in 
a  ward,  after  each  feeding  they  should  be  placed  in  carbolic  (i :  20). 

After  recover}',  the  room  should  be  disinfected.  Osier  shows 
that  1. 8 1  per  cent,  of  cases  of  typhoid  at  the  Johns  Hopkins  have 
been  of  hospital  origin.  I  have  noted  great  carelessness  in  our  hos- 
pitals as  regards  fly  protection,  seldom  observing  screening  of  the 
patient  during  the  fly  season.  Typhoid  cases  should  preferably  be 
kept  in  a  special  ward  to  avoid  the  danger  of  infection  of  other 
patients  through  carelessness.  Mabon  demonstrated  this  at  the 
Manhattan  State  Hospital. 

Chronic  Typhoid  Distribution. — Many  cases  are  discharged 
from  the  hospitals  while  there  are  still  typhoid  bacilli  in  the  urine 
and  stools.     Examinations  of  these  discharges  should  be  made. 

Urotropin,  gr.  5  to  10  (0.3-0.6),  with  an  equal  amount  of  sodium 
benzoate  t.  i.  d.  is  excellent  to  disinfect  the  urine. 

An  interesting  case  of  typhoid  carrier  of  nearly  seven  years' 
duration,  with  five  small  epidemics  to  her  credit,  is  reported  by 
George  A.  Soper.^  Wright  has  introduced  a  method  of  vaccination 
against  typhoid  which  proved  of  considerable  value  in  South  Africa. 

Treatment. — General  Management. — The  patient  should  be  in  a 
light,  well-ventilated  room,  confined  to  bed.     This  should  be  single,  - 
with  a  comfortable  mattress,  covered  with  a  blanket,  and  a  loibber 
cloth  placed  under  the  sheet.     Nursing  and  diet  are  the  essentials. 

Diet. — ^There  is  a  tendency  among  many  practitioners  to  endeavor 
to  increase  the  resisting  power  to  typhoid  by  increased  feeding,  and 
who  hold  that  for  this  purpose  the  patient  should  lose  as  little 
weight  as  possible.  In  some  cases  solid  food  has  been  administered ; 
in  others  liquids,  with  considerable  dextrose  and  cream.^  It  has  been 
thoroughly  demonstrated  that  no  matter  what  the  intake,  the  nitrog- 
enous output  in  this  disease  is  always  markedly  in  excess.^ 

Typhoid  is  an  acute  general  infection,  and  in  such  conditions  all 
the  digestive  functions  are  abnormal.  There  is  change  in  the  charac- 
ter of  the  bile.  Stolmkow*  noted  disturbances  in  the  pancreatic  juice ; 
and  I  recently  referred  to  the  diminution''  of  motor  power  and  the 
lessening  or  absence  of  hydrochloric  acid  during  the  high  temperature 
of  typhoid  fever.     The  parenchymatous    changes    n  the  liver  and 

'Journal  of  American  Medical  Association,  June  15,  1907. 

2W.  Coleman  (Jour.  Am.  Med.  Assoc,  Oct  9,  1909)  advocates  milk,  cream, 
milk-sugar,  and  eggs,  giving  from  4000  to  5500  calories  per  day,  and  reports  good 
results.  The  author  disagrees  with  a  method  which  places  upon  diseased  organs 
twice  the  labor  which  they  perform  in  health,  with  the  dangers  incident  to  ex- 
cessive feeding. 

^Finkler  and  Lichtenfeld,  Centralblatt  fiir  die  Allgemeine  Gesundheitspflege, 
igo2.  ■' Pfliiger,  Archiv.  Physiologic. 

5  Medical  Record,  June  20,  190S,  and  American  Medicine,  May,  1909. 


536  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

kidneys  interfere  with  elimination  by  these  organs,  and  the  asso- 
ciated intestinal  catarrh  causes  further  interference  with  the  digest- 
ive functions.  Seibert,  in  1889,  noted  that  temperature  and  tympa- 
nites were  lessened  when  milk  was  withheld,  the  fever  falling  to  99° 
or  100°  F.  on  the  ninth  to  twehth  days.  Rectal  irrigations  he  found 
of  great  value.  He^  gives  rectal  injections  with  3  pints  of  warm 
normal  saHne  solution,  preferably  several  times  a  day,  depending 
on  the  case,  thus  irrigating  the  bowel.  During  the  first  day  of  treat- 
ment cold  water  only  is  given  as  food.  From  the  second  day  on,  J 
pint  of  strained  rice,  oatmeal  or  barley  soup,  containing  the  extract 
of  ^  pound  of  meat  and  the  yelk  of  a  fresh  egg,  well  spiced,  are 
given  every  three  hours,  five  times  daily.  From  the  fourth  day  on, 
strained  pea,  lentil,  potato,  and  tomato  soup  with  rice,  were  added 
to  the  menu.  Two  or  three  zwiebacks  were  given  with  the  soup  at 
the  end  of  the  first  week.  Orange  juice  was  given  in  water  three 
times  daily.  Egg-albumen  was  not  given  on  account  of  the  proba- 
bility of  forming  toxins.  Before  each  meal  15  to  25  drops  of  hydro- 
chloric acid  were  administered  in  h  ounce  of  water.  No  alcohol  was 
given  except  to  topers,  and  camphorated  oil  was  employed  by  hypo- 
dermic if  stimulation  was  required.  Cold  baths  were  never  emplo^^ed, 
even  in  hyperpyrexia.  Sponging  was  added  if  necessary.  Opium 
was  only  used  in  bowel  hemorrhage. 

Lesser^  has  treated  all  fevers  above  102.5  °F.  with  water  alone, 
and  below  this  point  with  broths,  rice-  and  barley-water,  also  em- 
ploying enteroclysis.  Good  results  were  secured  by  these  methods 
in  typhoid  during  the  Spanish- American  War. 

The  author's  method  is  as  follows:  As  gelatin^  lessens  nitrogen 
excretion,  and  as  it  aids  in  preserving  weight,  and  furthermore 
causes  no  putrefaction  in  the  intestines,  it  is  of  some  value  as  a  food. 
It  also  lessens  tendency  to  hemorrhage. 

Approximately,  oiss  (48.0)  of  gelatin  in  oxij  (375  cc)  of  water, 
gives  a  12  per  cent,  solution.  This  gelatin  solution  can  be  slightly 
flavored  with  lemon,  vanilla,  or  with  a  pinch  of  sugar,  and  be  given 
in  divided  doses.  Strained  rice,  barley,  oatmeal,  and  chicken  broths, 
the  sum  total  not  over  i  quart  (liter) ,  are  also  to  be  given  in  divided 
doses  every  three  to  four  hours,  the  last  feeding  no  later  than  9  p.  m. 
This  makes  in  all  about  i^  quarts  (Hters)  of  nourishment.  The 
various  foods  are  alternated  for  variety.  The  patient  is  not  urged 
to  eat.  Whenever  the  temperature  reaches  102.5°  ^-  or  more, 
nothing  but  water  is  administered  until  it  falls  to  that  point.  The 
juice  of  several  oranges  is  given  during  the  day.     When  the  temper- 

1  Medical  Record,  June  20,  1908.  2  j^-,i(j.,  October  19,  1905. 

3  Xhe  ingestion  of  7.5  per  cent,  of  the  total  heat  requirement  of  the  organism 
in  the  form  of  gelatin  spares  23  per  cent,  of  the  body's  proteid.  Thus,  in  a  total 
of  2800  calories  required  by  a  man  of  154  pounds  (Chittenden),  210  calories  in 
gelatin  are  necessary;  i  gm.  of  gelatin  contains  4.1  calories,  so  about  50  gm.  of 
gelatin  are  required,  or  oiss  (48.0).  The  gelatin  and  cereal  gruels  approximate 
2000  calories,  all  that  can  be  digested  properly. 


TYPHOID    FEVER  537 

ature  falls  to  99-5°  F.,  the  gruels  are  thickened  and  the  yelks  of  4 
raw  eggs  added. 

At  least  I  ^  to  25  quarts  (liters)  of  water,  to  which  dilute  sulphuric 
acid,  TTLxx  (1.184  cc),  is  added,  are  to  be  drunk  by  the  patient 
during  the  twenty-four  hours.  Dilute  nitromuriatic  or  dilute  hydro- 
chloric acid  may  be  substituted. 

For  the  advocates  of  milk,  I  would  state  that  the  sour  milks,  such 
as  matzoon,  bacillac,  kumyss,  and  lactone-buttermilk,  are  preferable 
to  plain  milk.  Effervescence  should  be  allowed  to  a  great  extent  to 
pass  off  from  kumyss  before  administering,  and  it  is  preferable  to 
dilute  it  some  with  lime-water  or  water.  Matzoon  and  the  thicker 
sour  milks  should  be  diluted  one-half  with  plain  water,  or  Vichy  that 
has  become  flat,  to  avoid  distention.  Milk^  if  administered  should  be 
diluted  one-half,  preferably  with  barley-w^ater  or  rice  gruel.  About 
1^2  quarts  (liters)  of  milk  or  sour  milks  thus  diluted  could  be  given  in 
twenty-four  hours.  I  do  not  advocate  their  use.  Carbonated  waters 
while  effen,"escing  add  to  distention.  Sanatogen,  as  much  as  o  j  (32.0) 
in  divided  doses,  is  of  value,  given  in  the  broths.  The  bowels  are 
freelv  opened  by  calomel,  gr.  5  (0.3),  or  castor  oil,  oiss  (45.0),  on  the 
first  day,  and  thereafter  hot  sahne  enemata,  ij  liters  (1500  cc),  at 
110°  to  115°  F.,  or  if  gas,  enteroctysis  (recurrent),  i  gallon  is  given 
A.  M.  and  p.  M.  as  routine.  Hemorrhage,  perforation,  or  appendicitis  ■ 
are  the  only  contraindications.  There  is  one  exception  to  this  rule: 
gentle  bowel  irrigation  with  a  tube  and  funnel,  with  hot  normal  saline 
solution  at  120°  F.  during  hemorrhage,  lessens  tympanites  and  helps 
contract  the  vessels.  Performed  by  the  physician,  if  guarded  by  a 
hypodermic  of  morphin,  gr.  ^  (0.016),  to  prevent  subsequent  peristal- 
sis, I  believe,  with  Kaufmann,  the  procedure  to  be  of  value. 

Sponging. — With  diet  and  irrigation  of  the  bowels  iiib-baths  are 
rareh^  necessary.  Cold  sponging  with  alcohol  and  water,  combined 
with  friction  when  the  temperature  is  over  102.5  °  F.,  generally  suffices. 

Baths. — I  am  not  opposed  to  the  Brand  method  as  a  scientific 
procedure  for  its  additional  effects  on  the  pulse  and  on  elimination. 
If  the  friction  bath  is  given,  it  should  be  started  at  about  90°  F., 
-never  given  below  70°  F.     Often  the  warm  bath  is  preferable. 

Strychnin,  gr.  -gV  to  -gV  (0.00108-0.002 1),  or  Hoffmann's  anodyne, 
3j  (4.0),  may  be  required  in  the  bath.  The  average  duration  of  the 
bath  should  be  twenty  minutes,  longer  if  no  reduction  of  high  tem- 
perature.   If  the  patient  looks  blue  or  shivers,  he  should  be  removed. 

The  Nauheim  bath  (Triton  salts),  advocated  by  William  H.  Thom- 
son, especially  if  friction  is  combined,  is  superior  to  the  Brand  bath.  In 
Fig.  210  is  a  portable  tub,  weight  5  pounds,  excellent  for  private  work. 

Medicinal  Treatment. — Antipyretics  should  be  avoided.     Though 

1  In  100  cc.  of  milk  is  contained  only  64  calories,  or  640  calories  per  liter;  4 
quarts  (liters)  of  undiluted  milk  would  not  give  more  than  2800  calories  required 
for  a  man  weighing  154  pounds.  The  fallacy  of  pure  milk  diet  is  thus  demon- 
strated. Rice,  barley,  and  oatmeal  average  about  750  calories  per  100.  If  milk 
is  given,  its  calorie  value  and  digestibility  are  increased  by  these  cereals. 


538 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


Chantemesse  has  reported  some  results  from  serum-therapy,  it  is 
doubtful  whether  anything  of  value  has  yet  been  obtained,  though 
interesting  data  have  been  reported  on  the  injection  of  bacterial 
vaccines  by  Walters  and  Eaton. ^ 

Bismuth  subnitrate  or  subcarbonate,  in  a  dose  of  gr.  15  to  20 
(i. 0-1.3),  comxbined  with  the  same  quantity  of  saccharated  pepsin,  I 
employ  every  three  hours,  on  an  average  of  four  doses  a  day.  The 
bismuth  helps  control  the  ulcers.  As  urotropin  causes  disappearance 
of  the  bacilli  from  the  urine,  it  would  seem  a  logical  remedy.  Uro- 
tropin, gr.  5  to  10  (0.3-0.6),  given  preferably  wdth  equal  quantities 
of  sodium  benzoate  in  Yichy  w^hich'  has  become  flat,  is  the  best 
method.  It  should  be  administered  three  or  four  times  a  day.  I 
have  apparently  seen  some  benefit  in  lessening  the  temperature  and 
tympanites  by  this  method.     Acetozone  (i  :  1000),  given  in  divided 


Fig.  210. — Chambers'  portable  bath-tub. 

doses,  about  i  to  ij  quarts  (Hters)  per  day,  has  been  favorably  re- 
ported in  some  cases;  each  dose  is  flavored  with  orange  juice. 

Tympanites. — Hot  fomentations  and  turpentine  stupes  are 
employed.  The  ice-bag  is  best  in  many  cases.  A  rectal  tube  may 
be  inserted,  or  an  enema  containing  oil  of  turpentine,  oj  (4.0),  be 
given.  Spirits  of  turpentine,  'TTLx  to  xv  (0.592-1. 184),  can  be  given 
three  or  four  times  a  day,  or  resin  turpentine,  gr.  3  (o.i94)>  four 
times  a  day,  or  oil  of  cinnamon,  ITLiij  to  v  (0.178-0.296),  every  two 
hours.  Charcoal,  gr.  5  (0.3),  bismuth  subnitrate,  gr.  15  (i.o), 
beta-naphtol,  gr.  3  (0.194),  or  ichthalbin,  ichthoform,  or  formidin, 
gr.  5  (0.3),  every  three  to  four  hours  may  be  substituted.  Acute  dis- 
tention is  relieved  by  enteroclysis.  As  acute  dilatation  of  the  stomach 
1  Medical  Record,  January  16,  1909. 


TYPHOID    FEVER 


539 


is  often  associated,  lavage  is  also  of  value.  This  is  especially  true 
in  distention  with  active  hemorrhage. 

A  thorough  bowel  action  should  at  once  be  secured  if  there  is  no 
hemorrhage.    Eserin,  gr.  e^o  (0.00108)  by  hypodermic,  may  be  of  value. 

As  I  order  magnesium  sulphate  or  citrate,  oj  (4.0);  every  second 
or  third  day  in  addition  to  the  rectal  irrigation,  tympanites  is  rare. 

In  Fig.  2 1 1  is  illustrated  the  correct  position  to  relieve  pressure 
from  tympanites ;  pulse  and  respiration  lessened  20  points  as  a  result, 
and  the  tympanitic  area  in  the  thorax  diminished  4  inches. 

Diarrhea. — The  bismuth  preparations,  chalk,  and  occasionally  a 
little  opium  (see  chapter  on  Diarrhea)  may  be  required,  and  the  ene- 
mata  stopped  for  twenty-four  hours,  if  the  movements  are  excessive. 

Constipation  does  not  occur  with  the  methods  described. 


Fig.  211— Postural  treatment  for  acute  dilatation  of  stomach  and  intestines  in 

typhoid  fever. 

Hemorrhage.— Morphin,  gr.  {  (0.016),  by  hypodermic,  and  the  ice- 
bag  immediately  applied.  Then  lactate  of  calcium,  gr.  15  (i-o),  given 
with  5ij  to  iv  (60.0-125.0)  of  5  to  10  per  cent,  gelatin  solution;  chlo- 
rid  of  calcium,  gr.  10  (0.6),  may  be  substituted.  Thereafter  lactate 
of  calcium,  gr.  10  (0.6),  with  5ij  (60.0)  of  10  per  cent,  gelatin  every 
four  hours.     Ernutin,  Vf[v  (0.296),  may  be  given  by  hypodermic. 

William  H.  Thomson  recommends  the  following: 

I^.     Pulv.  opii  \  aa  gr.  V  (0.3) 

Argenti  nitratis  (    '  _..  ,      . 

Resin  turjjentine oy  A    *^^ 

Liquor  potassii ^J  ^^ 

Licorice  pulv. 1-  s-     •"■ 

Divide  into  60  pills.  ,        ■  r  r        ^^c-^c  of 

Sig._Two  pills  every  four  hours.     They  may  be  given  for  a  fev\    doses  at 
two-hour  intervals. 


540 


DISEASES   OF  THE   STOMACH  AND   INTESTINES 


Large  doses  of  opium  should  be  avoided,  as  they  obscure  symp- 
toms. 

Adrenahn  (i :  looo),  Ttl,v  to  x  (0.296-1.592),  has  been  advocated 
by  hypodermic,  but  it  may  increase  pulse  tension  too  markedly. 

Hypodermoclysis,  preferably  in  the  iliolumbar  region,  as  in  Fig. 
212,  with  normal  salt  solution,  may  be  required,  or  even  infusion. 

At  any  time,  on  the  appearance  of  blood  in  the  stool  or  of  sus- 
pected hemorrhage,  stop  enteroclysis  and  baths  (if  being  given)  at 
once. 

Perforation  and  Peritonitis. — Early  operation  is  indicated. 


Fig.  212. — Hypodermoclysis  in  the  iliolumbar  region. 


Heart  Stimulants. — Strychnin  sulphate,  gr.  -i^  to  3V  (0.00108- 
0.0026),  every  three  or  four  hours  by  hypodermic,  or 

I^.     Pulv.  camphor gr.  viiss  (0.5) 

Sterile  almond  oil TTLxJC  (1.184). 

Sig. — One  dose  every  four  to  six  hours  by  hypodermic  may  be  required, 
especially  if  there  are  complications. 

Aromatic  spirits  of  ammonia  or  Hoffmann's  anodyne,  in  oj  (4.0) 
doses,  are  useful  in  emergency 

Caffein  citrate,  gr.  i  to  2  (0.065-0.021)  every  three  or  four  hours, 
is  of  service. 

Some  advise  alcohol,  oviij  to  xij  (250-375  cc),  in  divided  doses, 
but,  like  Seibert,  I  have  not  found  it  necessary.  Large  doses  of 
tincture  of  digitalis  may  be  added  in  the  case  of  alcoholics.  Careful 
stimulation  with  drugs,  I  believe,  causes  less  strain  on  the  kidneys. 


TYPHOID   FEVER  54 1 

The  former  views  as  to  the  value  of  alcohol  as  a  food,  or  its 
power  to  increase  the  capacity  for  work,  seem,  by  scientific  research, 
to  be  pretty  thoroughly  exploded.  Its  use  in  the  arctic  regions, 
where  food  of  high  calorie  value  is  at  a  premium,  has  been  found  to 
be  deleterious.  In  sudden  emergency,  as  a  heart  stimulant,  it  is  of 
value,  but  its  prolonged  use  as  a  circulatory  tonic  has  been  shown 
to  be  harmful.  Proper  individual  dosage  is  difficult  to  estimate, 
and  the  strain  on  the  already  damaged  eliminating  organs  in  typhoid 
fever  is  severe.  F.  Lee  has,  moreover,  demonstrated  that  the  use 
of  alcohol  causes  muscle  fatigue. 

For  Nervous  Symptoms. — Warm  or  cool  packs  with  ice-bag  to 
the  head,  and  at  times  bromids  or  opiates. 

For  Sleeplessness. — Sulphonal,  trional,  or  veronal,  gr.  lo  (0.6). 

Bacilluria.^ — Uro tropin  and  benzoate  of  soda,  of  each  gr.  10  (0.6) 
t.  i.  d. 

Care  should  be  taken  to  guard  against  bed-sores.  Tender  toes 
should  be  protected  from  the  weight  of  the  sheets,  and  hyperexten- 
sion  of  the  feet  should  be  avoided.  In  some  cases  a  water-  or  air-bed 
or  an  old  sheepskin  spread  under  the  patient,  as  suggested  by  Thom- 
son, may  be  required. 

For  Renal  hisufpciency. — Cream  of  tartar  lemonade:  Cream  of 
tartar,  oj  (4.0);  juice  of  2  lemons;  saccharin,  gr.  j  (0.063);  water, 
I  quart  (liter).  Drink  in  divided  doses  during  the  day.  Recurrent 
enteroclysis  with  normal  saline  solution  at  120°  F.  and  proctoclysis 
are  useful.  Caffein  citrate,  gr.  v  (0.5)  t.  i.  d.,  is  of  value.  Hypo- 
dermoclysis  may  be  necessary. 

Colitis  should  receive  treatment  as  described  in  that  chapter. 
Delafield^  has  secured  results  in  membranous  colitis  by  irrigation 
with  2  quarts  (liters)  of  bichlorid  of  mercury  (i :  10,000)  with  the  re- 
current tube. 

Complications  should  receive  appropriate  treatment. 

Convalescence. — It  is  usually  preferable  to  have  a  normal  tem- 
perature for  a  week  before  commencing  with  solid  food.  Soft-boiled 
eggs,  milk  toast,  jellies,  and  a  little  scraped  beef  should  be  first  tried. 

In  some  prolonged  cases,  with  temperatures  of  99°  to  100°  F., 
cautious  feeding  may  be  attempted  with  the  above  materials.  I 
have  seen  temperature  fall  as  a  result. 

Bacilluria  I  believe  a  frequent  cause  of  slight  persistent  tempera- 
ture. This  should  receive  treatment  as  already  described.  The 
patient  should  first  sit  up  for  a  brief  period  about  the  tenth  day  of 
normal  temperature. 

1  In  infection  of  the  kidneys  by  the  colon  bacillus,  Wm.  H.  Thomson  advises 
active  catharsis,  followed  by  frequent  doses  of  urotropin  and  sodium  benzoate, 
aa  gr.  x  (0.6),  every  three  hours.     If  not  retained  by  mouth,  give  by  enema. 

2  Enterodysis,  Hypodermoclysis,  and  Infusion  (Kemp). 


CHAPTER   XXVI 

INTESTINAL  HEMORRHAGE;  INTESTINAL  ULCERS; 
DISEASES  OF  THE  BLOOD-VESSELS  (EMBOLISM 
AND  THROMBOSIS) 

INTESTINAL  HEMORRHAGE 

It  would  seem  advisable  to  refer  to  the  various  causes  of  intes- 
tinal hemorrhage  for  the  purpose  of  diagnosis.  iVmong  such  are 
dysentery,  tvphoid,  yellow  fever,  malarial  poisoning,  ulceration 
from  various  causes,  cancer  scurvy,  purpura,  traumatism,  volvulus, 
intussusception  after  reduction  of  a  strangulated  hernia,  excessive 
use  of  laxatives,  hemorrhoids,  injury  (traumatism),  venous  hyperemia 
of  the  intestines  due  to  diseases  of  heart  or  lungs,  stasis  or  obstruction 
of  the  portal  system,  such  as  cirrhosis  of  the  liver,  injury  from  dried 
scybalae,  ankylostoma,  isolated  venous  varicosities,  arterial  aneurysms 
of  the  intestinal  wall,  aneurysms  in  adjacent  arteries,  as  of  the  hepatic, 
from  which  blood  may  enter  the  bile-passages  and  be  passed  by  the 
bowel. 

A  peculiar  type  of  enterorrhagia  occurs  with  no  anatomic  changes, 
but  there  is  probably  an  alteration  in  the  walls  of  the  blood-vessels. 
Thus,  intestinal  hemorrhages  have  occurred  in  phthisis  when  there 
were  no  ulcers. 

Intestinal  hemorrhages  in  pernicious  anemia,  leukemia,  scur^^y, 
morbus  maculosus,  septicemia,  icterus,  phosphorus-poisoning,  inter- 
mittent fever,  and  erysipelas  probably  belong  to  this  class.  Amy- 
loid degeneration  may  be  complicated  by  intestinal  hemorrhages. 
Some  believe  vicarious  hemorrhage  may  take  the  place  of  menstrua- 
tion. 

There  may  be  collapse,  with  all  the  symptoms  of  internal  hemor- 
rhage, and  blood  may  or  may  not  pass  from  the  rectum.  The  blood 
may  be  bright  red,  brown,  or  like  coffee-grounds. 

No  visible  blood  may  appear  in  the  stools  and  be  detected  only 
by  tests  for  occult  blood. 

Microscopic  examination  may  show  the  presence  of  red  blood - 
corpuscles  and  hematin. 

Treatment. — The  immediate  hemorrhage  should  be  treated  as 
described  under  Hemorrhage  in  Typhoid,  and  the  cause  should  be 
determined  and  treated. 

542 


ULCERS   OF   THE    INTESTINES  543 

ULCERS   OF  THE   INTESTINES 
Simple  Duodenal  Ulcer 

{Synonyms. — Duodenal  Ulcer;  Ulcus  Duodeni  Pepticum — Leube;  Round  or  Per- 
forating Duodenal  Ulcer.) 

This  is  characterized  by  a  defect  of  the  mucous  membrane  of  the 
duodenum,  usuahy  tending  to  run  a  protracted  course,  though 
in  some  instances  it  may  be  acute.  It  presents  the  appearance' 
and  characteristics  of  ulcer  of  the  stomach. 

Etiology.: — This  is  practically  the  same  as  gastric  ulcer,  being 
caused  by  the  action  of  the  acid  gastric  juice  upon  the  mucous 
membrane  of  the  duodenum,  whose  nutrition  and  \dtality  have 
previously  been  impaired  as  a  result  of  circulatory  derangement. 
Chlorosis,  however,  seems  to  play  no  part  in  its  production. 

Duodenal  ulcers  occur  from  burns  of  the  abdomen,  but  are  not 
correctly  classified  under  peptic  duodenal  ulcer.  Duodenal  ulcer 
is  less  frequent  than  gastric  ulcer,  but  is  much  more  frequent  than  is 
generally  supposed.  Undoubtedly  many  cases  have  been  diagnosed 
as  gastric  ulcer  when  it  was  a  duodenal  ulcer,  lying  close  to  the 
pyloric  ring.  William  J.  Mayo  has  demonstrated  that  many  pyloric 
ulcers  are  found  to  have  their  origin  in  the  duodenum,  and  in  many 
cases  it  is  impossible  to  differentiate  between  the  two  conditions. 
Trier  places  it  as  i  to  9  gastric  in  frequency;  while  Andral  as  i  to  40 
gastric ;  while  Starke  places  it  at  i  to  1 2  gastric. 

Age. — It  occurs  more  frequently  between  the  ages  of  fifteen  and 
sixty.  The  average  age  of  death  in  127  fatal  cases  w^as  thirty-eight 
years  (Rolleston),  but  the  Fen  wicks  show  that  in  the  acute  cases 
68  per  cent,  prove  fatal  between  fifteen  to  thirty  years,  and  in  chronic 
cases,  between  thirty  and  thirty-five. 

Duodenal  ulcer  occurs  quite  frequently  in  young .  children  of 
one  to  ten  years,  and  has  been  found  in  the  newborn  infant. 

Gastric  ulcers  occur  less  frequently  in  young  children. 

Sex. — The  proportion  of  males  affected  by  duodenal  ulcer  is  greater 
than  the  females. 

Weir  reports  30  women  in  176  cases;  Collins,  52  women  in  257 
cases;  others  give  the  rates  from  5  to  i  to  3  to  i. 

Pathology. — It  resembles  the  gastric  ulcer,  having  a  punched- 
out  appearance;  it  is  oblong  or  oval,  having  a  funnel  shape,  and 
extends  to  a  variable  depth.  It  is  only  irregular  in  shape  when  sev- 
eral ulcers  have  coalesced.  It  varie  in  size  from  a  pea  up  to  a  silver 
dollar.  William  Mayo  classifies  them  surgically  as  indurated  and 
non-indurated.  In  the  former  case  they  have  a  callous  margin.  The 
base  is  formed  usually  of  the  intestinal  wall  (muscle),  or  at  times 
by  adhesions  to  adjacent  organs. 

Site  of  the  Ulcer. — It  is  usually  present  in  the  upper  2  inches 
of  the  duodenum,  in  the  ascending  part  near  the  pylorus,  or  in 
the  upper  horizontal  part;  less  frequently  in  the  descending  part, 
and  rarely  in  the  third  horizontal  part.      If  the  ulcer  is*  situated 


544  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

near  the  diverticulum  of  Vater,  through  cicatricial  contraction  it  may 
occlude  the  orifices  of  the  bile-  and  pancreatic  ducts  and  produce 
complications. 

Usually  there  is  one  ulcer,  more  rarely,  two  to  four.  They  vary 
in  size  from  a  lentil  to  a  dollar. 

Complications. — Stenosis  of  the  duodenum  near  the  pylorus 
or  at  a  greater  distance  ma}^  occur,  with  resulting  dilatation  of  the 
stomach  and  symptoms  of  benign  stricture,  the  same  as  in  the  ste- 
nosis of  gastric  ulcer.  Jaundice,  distention  of  the  gall-bladder,  and 
inflammatory  conditions  therein  may  result  from  stenosis  blocking 
the  common  bile-duct.  Atrophy  of  the  pancreas  may  take  place 
from  closure  of  the  pancreatic  duct.  Fatal  hemorrhage  may  occa- 
sionally occur.     The  type  of  hemorrhage  is  usually  severe. 

In  acute  cases  quite  frequently  perforation  and  general  peritonitis 
occur,  with  death  from  shock  or  peritonitis.  If  the  process  is  more 
slow,  there  may  be  circumscribed  peritonitis  with  abscess.  There 
may  be  adhesions  with  other  organs  and  ulceration  involving  the  liver, 
gall-bladder,  pancreas,  aorta,  portal  vein,  or  hepatic  artery.  Sub- 
phrenic abscess  may  result. 

Thrombosis  of  the  portal  vein  has  also  occurred  through  deep 
cicatrization  of  an  ulcer.  The  blood-vessels  in  the  upper  and  descend- 
ing duodenum  have  frequently  been  eroded.  Cancer,  developed 
on  the  base  of  a  duodenal  ulcer,  has  been  reported  by  Arnold,  Eich- 
horst,  and  S.  Fen  wick. 

Clinical  Aspects. — Occasionally  the  cicatrix  of  an  old  ulcer 
may  be  found  at  autopsy,  though  there  have  been  no  symptoms 
during  life.  Other  patients  may  be  apparently  in  perfect  health, 
when  suddenly  a  severe  and  dangerous  intestinal  hemorrhage  takes 
place,   or   perforation   and   peritonitis. 

Symptoms. — In  some  cases  there  are  quite  marked  symptoms. 
The  patient  may  complain  of  tension  and  pressure  in  the  epigastric 
region  that  may  occur  without  apparent  cause,  or  after  eating,  or 
on  palpation.  In  many  cases  there  are  paroxysmal  attacks  of  pain 
that  may  be  quite  violent,  which  are  difficult  to  distinguish  from 
cardialgia  or  gall-stone  colic.  They  are  more  frequently  to  the 
right  of  the  linea  alba  and  extend  to  the  right,  in  a  line  below  the 
liver.  As  a  rule,  the  pains  do  not  radiate  to  the  back  as  in  gastric 
ulcer,  but  rather  downward  in  the  abdominal  cavity.  There  are 
interv^als  free  from  pain.  Pain  usually  occurs  from  two  to  three 
hours  after  meals.  Some  claim  the  period  of  pain  is  later,  four  to 
six  hours  after  eating,  which  aids  diagnosis.  I  have  not  found  this 
to  be  so. 

Though  the  region  near  the  pylorus  is  found  to  be  slightly  sensitive 
on  pressure,  there  does  not  seem  to  be  the  usual  circumscribed  and 
very  sensitive  spot,  as  found  in  gastric  ulcer.  In  some  cases  there 
may  be  continuous  pain  and  tenderness,  probably  due  to  local 
peritonitis. 


ULCERS   OF   THE    INTESTINES  545 

In  Others  there  is  a  boring  or  gnawing  sensation  in  this  region. 
Vomiting,  which  reUeves  the  pain  of  gastric  ulcer,  is  said  not  to 
do  so  in  duodenal  ulcer.  Fluid  given  at  the  time  of  pain  is  said 
to  lessen  it  by  causing  reflex  closure  of  the  pylorus  or  by  diluting 
the  excess  of  acid.  The  appetite  and  stools  may  be  normal.  Con- 
stipation frequently  occurs,  diarrhea  rarely.  The  general  condition 
of  the  patient  is  often  good  and  there  may  be  no  great  loss  of  weight. 
Vomiting  is  rare,  unless  there  is  stenosis  with  gastric  dilatation. 
Gastric  Contents  and  Vomitus. — In  my  own  experience  I  have 
generally  found  hyperchlorhydria  present,  which  corresponds  with 
Boas'  findings.  This  is  in  the  uncomplicated  cases.  Normal  contents, 
hypochlorhydria,  or  even  the  absence  of  free  hydrochloric  acid  and 
the  presence  of  lactic  acid  have  been  reported. 

Hemorrhage  is  a  very  frequent  symptom  and  occurs  in  at  least 
one-third  of  the  cases.  The  number  is  undoubtedly  much  larger,  if 
care  were  taken  to  examine  the  stools  and  gastric  contents  for  oc- 
cult blood^  by  Weber's  or  the  benzidin  test.  The  blood  is  most  fre- 
quently passed  by  the  bowel  and  less  frequently  vomited.  There  may 
be  severe  hemorrhage  retained  in  the  bowel,  with  all  the  symptoms 
of  collapse,  or  blood  passed  of  a  tar-like  or  coffee-ground  appearance. 
The  death-rate  from  hemorrhage  is  quite  large,  estimated  at 
13  to  33  per  cent,  in  acute  and  chronic  cases. 

Jaundice^  is  rare.  With  perforation  there  are  pain,  distention, 
muscular  rigidity,  etc. 

William  Mayo  has  shown  that  the  onset  of  perforation  is  extremely 
acute,  and  the  early  pain  is  just  to  the  right  of  the  median  line,  while 
in  gastric  perforation  it  is  usually  to  the  left  of  this  line. 

In  duodenal  perforation  the  contents  gravitate  at  once  to  the 
appendical  region,  and  simulate  perforated  appendix. 

The  course  may  be  very  acute  or  very  chronic.  Hemorrhage 
and  complications  are  common. 

Diagnosis. — In  many  cases  differential  diagnosis  between 
duodenal  and  gastric  ulcer  cannot  be  made.  Acute  cases  following 
burns  are  easv  of  diagnosis. 

The  following  are  of  ser^dce:  Duodenal  ulcer  is  much  more  fre- 
'quent  in  males;  pain  is  more  frequent  to  the  right  of  the  median  line 
and  does  not  radiate  to  the  back ;  local  circumscribed  tenderness  on 
pressure  not  as  marked  as  in  ulcer;  vomiting  rare,  unless  stenosis; 
melena  quite  frequent;  hematemesis  is  rarer  than  in  ulcer;  patients 
generallv  healthy  in  appearance;  intestinal  hemorrhage  very  fre- 
quent ;  perforation  verv  frequent ;  pain  in  some  cases  at  a  later  period 
than  with  stomach  ulcer;  latent  type  with  sudden  hemorrhage  more 
common  than  with  gastric  ulcer.  Though  Leube  states  that  hyper- 
chlorhydria is  present  in  gastric  ulcer  and  normal  acidity   or  dimm- 

1  Occult  blood  at  least  can  at  some  time  be  found  in  every  case. 

2  The  development  of  icterus,  in  a  case  presenting  some  of  the  symptoms  ot 
gastric  ulcer,  probably  shows  duodenal  ulcer,  if  gall-stones  can  be  excluded. 

35 


546  DISEASES   OF   THE   STOMACH  AND  INTESTINES 

ished  acidity  in  duodenal  ulcer,  so  far  in  the  uncomplicated  cases  I 
have  found  hyperacidity.  Occult  blood  ^  in  the  stool  is  quite  diag- 
nostic. 

The  prognosis  is  quite  serious,  especially  in  the  cases  with  frequent 
recurrent  hemorrhage.  Relapses  may  occur  in  the  apparently  cured 
cases,  but  I  have  seen  complete  recovery  follow  proper  treatment. 

Treatment. — This  is  similar  to  ulcer  of  the  stomach.  For  acute 
hemorrhage,  ice-bag  to  epigastrium,  morphin,  gr.  ^  (0.016). 

Tremo  lie  re's  solution — calcium  chlorid  (2  per  cent,  solution)  in 
gelatin  (5  per  cent,  solution) — oj  (30.0),  every  two  to  three  hours. 

Gelatin  (10  per  cent.)  by  mouth,  oj  (30.0),  or  2  per  cent,  subcu- 
taneously ;  calcium  chlorid  or  calcium  lactate,  gr.  10  (0.6) ,  by  mouth  or 
enema;  or  strontium  or  magnesium  lactate  by  hypodermoclysis,  gr.  15 
to  30  (1.0-2.0),  in  oiv  (125  c.c.)  sterile  water,  or  ernutin,  TTLv  (0.296). 

Adrenalin  (i :  1000),  lllv  (0.296)  or  more,  has  been  recommended 
by  mouth  or  hypodermic.     It  may  too  markedly  raise  pulse  tension. 

For  collapse,  rectal  saline  enema,  proctoclysis,  or  hypodermo- 
clysis, with  camphorated  oil  or  strychnin  by  hypodermic.  Rectal 
feeding  for  twelve  hours  and  white  of  egg  and  gelatin  (cold)  by 
mouth. 

Subsequently,  large  doses  of  bismuth,  and  nitrate  of  silver  should 
be  given,  as  in  gastric  ulcer.  Treat  hyperchlorhydria,  if  present, 
and  feed  by  Lenhartz's  method,  as  for  ulcer  of  stomach.  Iron  and 
arsenic  for  anemia.     Regulate  the  bowels 

Surgery. — Perforation  requires  immediate  operation;  for  fre- 
quently repeated  large  hemorrhages  and  for  gastric  dilatation  gastro- 
enterostomy is  indicated.  Local  abscess,  adhesions,  or  obstructive 
jaundice  require  operation. 

Intestinal  Ulcers  from  Cutaneous  Burns 
Ulcers  from  extensive  burns  (cutaneous)  generally  occur  in  the 
upper  transverse  duodenum,  seldom  lower  down.  Rarely  an  ulcer 
may  occur  in  the  stomach  or  other  part  of  the  intestines.  There 
may  be  a  single  ulcer  or  five  or  six  of  them.  There  is  considerable 
loss  of  tissue  in  some  cases,  in  others  erosions,  and  at  times  inflamma- 
tion of  the  mucous  membrane.  The  shape  of  the  ulcer  is  irregular 
and  dentate  or  long  and  narrow. 

The  course  is  very  acute,  the  result  generally  fatal;  hemorrhage 
or  perforation  occurring  within  one  to  two  weeks  after  the  burn  or 
even  within  two  to  three  days.  The  condition  is  probably  due  to 
septic  embolism.  Operate  if  there  is  perforation.  In  viild  cases 
treatment  is  that  of  duodenal  ulcer.  Intestinal  hemorrhage  and 
local  tenderness  are  the  salient  symptoms. 

1  The  determination  of  occult  blood  in  the  stool,  and  at  times  occasionally  in 
the  vomitus,  is  of  valuable  diagnostic  import.  In  an  obscure  case  at  the  Red 
Cross  Hospital,  a  positive  diagnosis,  ulcer  of  the  duodenum,  was  made  chiefly  on 
this  point  and  confirmed  at  operation  by  H.  Haubold.  It  served  to  exclude  gall- 
bladder disease  and  a  gastric  neurosis. 


ulcers  of  the  intestines  547 

Embolic  and  Thrombotic  Ulcers 

Parenski^  first  described  this  condition.  These  ulcers  originate 
from  emboli  which  are  carried  into  the  small  branches  of  the  mesen- 
teric arteries  from  an  endocarditis  or  atheromatous  degeneration  of 
the  aorta,  from  an  abscess  focus  or  foci,  or  from  thrombosis,  as  a 
result  of  endarteritis.     They  occur  in  the  jejunum,  ileum,  and  colon. 

If  the  embolus  is  aseptic,  infarction  with  hemorrhagic  infiltration 
occurs  and  necrosis  results  with  the  production  of  an  ulcer.  The  ulcers, 
as  a  rule,  are  small,  circular,  or  irregular  in  outline.  Occasionally  the 
whole  thickness  of  the  intestines  may  become  involved,  so  that  peri- 
tonitis of  a  fibrinous  or  purulent  type  occurs,  or  at  times  perforation. 
These  ulcers  occur  in  the  area  of  distribution  of  the  occluded  vessels. 

Infarction  of  the  spleen  and  kidneys  may  be  present.  If  the 
emboli  are  septic,  numerous  small  abscesses  are  seen  in  the  sub- 
mucosa,  which  may  break  down  and  form  ulcers. 

Small  nodules  (miliary  abscesses),  consisting  of  round  cells 
surrounding  a  blood-vessel,  are  at  times  found  post  mortem  in  fatal 
cases,  not  yet  having  broken  down  into  ulcers.  Colicky  pains, 
tenderness,  diarrhea  with  blood  and  pus,  occurring  in  cases  in  whom 
embolic  processes  can  be  discovered  in  other  organs,  or  when  a  cause  for 
emboli  can  be  found,  render  the  diagnosis  of  embolic  ulcer  probable. 

Intestinal  ulceration  occurring  with  multiple  degenerative 
neuritis  probably  belongs  to  the  class  of  thrombotic  ulcers,  there 
being  degenerative  changes  (arteritis)  influenced  by  the  neuritis 
(trophic).     Fracture  of  the  spine  has  resulted  in  intestinal  ulceration. 

Amyloid  Ulcers 

This  type  of  intestinal  ulcer  is  rare,  and  would  only  be  suspected 
when  associated  with  amyloid  degeneration  of  other  organs,  such  as  of 
the  liver,  spleen,  in  cases  suffering  from  long-continued  suppuration, 
cachexia,  tuberculosis,  syphilis,  rickets,  or  leukemia.  There  would 
be  diarrhea,  symptoms  of  ulcer,  and  deficient  absorption  from  the 
intestines.  Amyloid  ulcers  may  be  found  in  any  part  of  the  intestinal 
tract,  though  more  usually  in  the  small  intestine.  They  are  gener- 
-ally  multiple  and  may  involve  large  areas.  They  are  from  the  size 
of  a  pea  to  large  girdle  ulcers,  nearly  circumscribing  the  bowel. 

Leube  believes  the  ulcers  originate  from  circulatory  disturbances 
due  to  amyloid  degeneration  of  the  walls  of  the  small  arteries.  The 
vessels  of  the  mucous  membrane  are  first  affected,  but  the  process 
may  involve  the  entire  coat  of  the  bowel.  The  ulcers  have  no 
tendency  to  heal.  Other  areas  of  intestines  between  the  ulcers  ma$r 
be  in  a  condition  of  amyloid  degeneration.  The  mucous  membrane 
is  pale  and  waxy  in  appearance  and  some  of  the  villi  are  missing. 

On  post  mortem  a  weak  solution  of  iodin  gives  a  mahogany- 
brown  color,  the  test  for  amyloid  degeneration.  The  addition  of 
sulphuric  acid  turns  it  violet  or  blue. 

iWienermcd.  Jahrl)uchcr,  1.S76,  Heft.  3. 


548  diseases  olf  the  stomach  and  intestines 

Tubercular  Ulcers  and  Intestinal  Tuberculosis 

Tuberculosis  is  a  quite  frequent  cause  of  ulceration  of  the  intes- 
tines. The  infection  may  be :  (i)  Primary  in  the  intestinal  mucous 
membrane;  (2)  most  commonly  secondary  to  diseases  of  the  lungs; 
and,  rarely,  (3)  secondary  to  tubercular  peritonitis. 

Primary  intestinal  tuberculosis  occurs  most  frequently  in  children, 
and  with  it  may  be  associated  tuberculosis  of  the  mesenteric  glands 
or  tubercular  peritonitis. 

R,  Koch  believes  that  bovine  tuberculosis  differs  from  human 
tuberculosis,  and  that  infection  from  diseased  milk  or  milk  of  tuber- 
culous cattle  hardly  ever  occurs,  and  it  is  unnecessary  to  take  any 
precautions.     Von  Behring  takes  the  opposite  view. 

In  the  Charite  Hospital  in  Berlin  there  were  only  10  cases  in  ten 
years.  In  3104  cases  of  tuberculosis  in  children,  there  were  16  of 
primary  infection.  There  have  been  investigations  recently  reported 
which  are  suggestive  that  infection  through  the  intestines  is  more 
common  than  we  suppose,  notably,  Macfayden  found  tubercle  bacilli 
in  the  mesenteric  glands  of  5  out  of  20  children  post  mortem,  with 
no  tubercular  lesions  elsewhere;  and  Ravenal  in  8  cases  out  of  25. 

Recent  consensus  of  opinion  holds  that  primary  intestinal 
infection  occurs  through  tuberculous  milk.  Milk  from  an  infected 
nurse  or  mother  may  also  be  a  cause.  The  meat  of  tuberculous 
cattle  probably  plays  a  lesser  role,  as  it  is  generally  thoroughly 
cooked.  There  is  no  reason  why  other  raw  food  products  may  not 
be  occasionally  a  source  of  infection,  especially  if  exposed  to  infection 
by  flies  or  sources  of  contamination.  In  adults  primary  intestinal 
tuberculosis  is  rare  (in  the  Munich  Pathologic  Institute  i  in  1000 
cases).  The  lower  ileum  is  usually  first  involved  and  then  the  rest 
of  the  small  intestine  and  colon. 

Symptoms. — The  condition  may  begin  with  irregular  diarrhea, 
slight  fever,  and  colicky  pains.  Rarely,  hemorrhage  may  be  the 
first  symptom.  At  first  the  symptoms  may  simulate  a  chronic 
catarrh.  Until  subsequent  emaciation  becomes  marked  or  an  involve- 
ment of  the  lungs  occurs,  the  condition  may  not  be  suspected.  The 
stools  in  every  doubtful  case  should  be  examined  for  Koch's  tubercle 
bacillus,  which  is  diagnostic.  The  tuberculin  test,  by  injection  or 
ocular,  should  be  made. 

A  deceptive  condition  is  when  the  ulceration  begins  in  the  cecum, 
and  there  are  symptoms  suggestive  of  appendicitis,  with  tenderness 
ifi  the  right  iliac  fossa,  constipation,  or  irregular  diarrhea.  Osier 
reports  in  his  primary  cases  of  intestinal  tuberculosis  occasional 
fatal  hemorrhage  or  perforation,  with  the  formation  of  pericecal 
abscess  or  perforative  peritonitis,  or,  rarely,  partial  healing,  with 
great  thickening  of  the  intestinal  walls  and  narrowing  of  the  canal 
(chronic  hyperplastic  tuberculosis). 


ULCERS   OF  THE   INTESTINES  549 

Secondary  Tubercular  Ulcers  of  the  Intestines  (  Tuberculosis  j 

These  are  very  common  in  chronic  pulmonary  tuberculosis. 
Frerichs^  found  tuberculosis  of  the  ileum  in  80  per  cent,  of  these 
cases.     In  566  of  1000  Munich  autopsies  secondary  tuberculosis  was 
found  in  the  ileum,  cecum,  or  colon,  and  in  all  but  3  the  lungs  were 
involved.     Swallowing  tuberculous  sputum  is  the  cause. 

The  lowest  part  of  the  ileum  is  the  chief  point  of  infection  with 
ulcers.  It  often  extends  to  the  cecum,  colon,  or  rectum,  and  upward 
to  the  jejunum  or  even  duodenum.  Tuberculous  ulceration  has 
even  occurred  in  the  stomach.  At  times  tuberculous  ulcers  develop 
primarily  in  the  colon.  The  development  of  the  tuberculous  ulcer  is 
preceded  by  the  formation  of  a  mihary  tubercle.  It  usually  begins 
in  the  solitary  or  agminated  follicles.  Caseation  and  necrosis  of  the 
tubercle  lead  to  ulceration.  In  Peyer's  patches  only  isolated  follicles 
are  at  first  involved,  while  in  typhoid  and  intestinal  catarrh  they  are 
uniformly  affected.  Ulceration  at  first  occurs  in  certain  points  of  the 
plaque,  but  later  it  becomes  entirely  involved,  and  the  ulcer,  there- 
fore, may  be  ovoid.  This  occurs  in  the  ileum.  In  the  jejunum  and 
colon  they  may  be  round,  but  usually  lie  transverse  to  the  long  axis. 
The  chief  characteristics  of  the  tuberculous  ulcer  are  as  follows: 

It  is  irregular  in  shape,  more  rarely  ovoid,  and  generally  extends 
along  the  transverse  axis  (girdle  ulcer) ;  the  margin  is  a  light  red 
color;  the  edges  and  base  are  infiltrated  and  often  caseous.  The 
submucous  and  muscular  coat  are  usually  involved,  and  on  the 
serosa  are  mihary  tubercles  or  a  marked  tubercular  lymphangitis. 
The  serosa  is  reddened  and  thickened,  covered  with  layers  of  fibrin, 
and  is  often  adherent  to  the  mesentery  or  other  loops  of  the  intestines. 
As  compared  with  the  great  frequency  and  number  of  tuberculous 
ulcers,  perforation  is,  therefore,  not  frequent.  There  may  be  stenosis 
from  cicatrization  of  the  ulcers  and  this  may  be  multiple.  They 
do  not,  as  a  rule,  show  much  tendency  to  heal.  Swelling  and  tuber- 
culous'infection  of  the  mesenteric  glands  are  often  present. 

Secondary  infection  of  the  intestines  from  the  peritoneum  may  pro- 
ducetuberculousulceration.Theaffectionmaybeprimarilymthe  peri- 
toneum, or  extend  from  the  Fallopian  tubes  or  mesenteric  glands.  The 
intestinal  coils  may  mat  together,  containing  caseous,  suppurating  foci. 
There  may  be  the  pecuHar  localized  form  of  tuberculous  tumor 
from  a  chronic  hyperplastic  tuberculosis  occurring  in  the  ileocecal 
region,  to  which  I  have  already  referred.  It  may  simulate  a  new 
growth  and  cause  constriction  of  the  lumen  of  the  bowel. 

There  may  be  a  chronic  hyperplastic  tuberculosis  of  the  intestines 
with  thickening  of  the  gut.  There  is  no  definite  tumor  to  be  felt,  but 
the  induration  in  the  right  iliac  fossa,  when  it  occurs  there,  is  similar 
to  a  recurring  appendicitis.  It  may  attack  other  parts  of  the  intes- 
tines. Tuberculosis  of  the  rectum  may  occur,  with  fistula  m  ano. 
iBeitrage  zur  Lehre  von  dcr  Tuberculosc,  Marburg,  1882. 


550  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

Tubercle  bacilli  in  the  stools  are  diagnostic  of  these  conditions 
when  found;  otherwise  they  are  difficult  of  diagnosis  unless  by 
operation.  The  symptoms  and  treatment  of  tuberculous  ulcer 
(tuberculosis)  of  the  intestines  will  be  described  at  the  end  of  this 
chapter. 

Catarrhal  and  Follicular  Ulcers 

These  types  of  ulcer  occur  in  the  course  of  catarrhal  inflammation 
of  the  intestinal  mucous  membrane,  and  are  described  in  that  chapter. 

Ulcerative  Colitis 

This  special  form  of  ulceration  of  the  colon  was  first  described 
by  Hale  White,  colitis  occurring  especially  in  institutions  and  insane 
asylums.  Probably  the  greater  percentage  of  these  so-called  cases 
of  colitis,  such  as  occur  in  institutions,  are  true  dysentery. 

Vedder  and  Duval,^  while  working  under  Flexner,  found  that 
institutional  outbreaks  were  due  to  Bacillus  dysenteriae.  Osier 
and  J.  P.  Tuttle  differ  in  this  regard  and  classify  it  as  non-dysenteric. 
The  symptoms  and  treatment  are  of  dysentery. 

Stercoral  or  Decubital  Ulcers 

These  ulcers  are  produced  by  the  pressure  of  hardened  and 
stagnating  feces  on  the  mucous  membrane,  resulting  in  necrosis  and 
purulent  inflammation.  They  develop  particularly  in  the  cecum, 
flexure  of  the  colon  (hepatic  and  splenic),  sigmoid  flexure,  and  the 
rectum,  where  stasis  is  most  apt  to  occur.  Fecal  concretion  in  the 
appendix  is  fair-ly  common  and  may  produce  ulcer  and  appendicitis. 
They  sometimes  develop  in  chronic  intestinal  stenosis  above  the  seat 
of  stricture. 

Ulcers  in  Acute  Infectious  Diseases 

Under  this  group  are  the  specific  ulcers  of  typhoid  and  dysentery; 
diphtheritic  ulceration;  ulcers  of  sepsis;  rarely  duodenal  ulceration 
in  erysipelas;  in  varioloid;  ulcer  of  the  duodenum  in  pneumonia, 
a  rare  occurrence.  In  acute  pemphigus  and  in  pellagra  isolated 
cases  have  been  reported. 

Ulcers  in  Constitutional  Diseases 

In  acute  leukemia,  lymphatic  tumors  may  occur  in  the  intestines, 
especially  in  the  ileum,  and  break  down,  with  the  production  of 
ulcers.  This  is  rare  in  the  chronic  type.  Intestinal  ulceration  has 
occurred  in  scurvy  and  a  few  isolated  cases  are  reported  in  gout. 

Toxic  Ulcers 
Intestinal    ulcers    occur    in    nephritis,    with    uremic    symptoms 
associated  with  the  intestinal  catarrh.     They  He  chiefly  in  the  large 
intestine. 

1  Journal  Exp.  Med.,  Feb.  5,  1902,  vol.  vi. 


ULCERS   OF   THE   INTESTINES  55 1 

In  poisoning  with  mercury  they  are  also  found,  even  when  it 
is  not  administered  by  mouth  or  rectum,  but  by  inunction. 

Changes  in  the  blood  have  been  held  responsible  for  these  con- 
ditions. With  nephritis  the  intestinal  catarrh  is  probably  a  factor; 
it  is  believed  by  many  that  the  mercury  reaches  the  intestines  by 
excretion  in  the  bile,  and  produces  direct  inflammation  with  result- 
ant ulcer,  in  which  decomposition  or  intestinal  bacteria  play  a  part, 
since  we  find  in  some  cases  a  pseudodiphtheritic  membrane. 

Syphilitic,  Gonorrheal,  and  Cancerous  Ulcers 

Syphilitic  ulceration  of  the  intestines  is  rather  rare.  In  the 
small  intestine  it  may  be  found  in  a  young  infant  with  inherited 
syphilis.  Ulcers  originate  in  the  lymphatics  or  in  the  mucosa  or 
submucosa,  from  a  gumma  which  gradually  breaks  down.  A  few 
cases  of  syphilitic  ulcer  of  the  small  intestine  in  an  adult  have  been 
reported  by  Klebs,  Osier,  and  Birch-Hirschfeld.  These  ulcers  are 
rarely  encountered  in  the  large  intestine,  except  in  the  rectum  in  its 
lowest  part.  Primary  chancre  of  the  rectum  has  been  observed. 
If  feasible,  the  test  for  the  Wassermann  reaction  should  be  made 
to  confirm  the  diagnosis.  The  physical  examination  and  history  of 
the  case  are  important. 

Condylomata  and  gummata  may  break  down,  and  by  cicatrization 
give  rise  to  stricture  of  the  rectum. 

Virchow  notes  that  syphilitic  ulcers  are  of  slight  depth  and  have 
a  smooth  base.     They  are  more  frequent  among  women  than  men. 

Polchen^  found  190  cases  of  stricture  among  women  out  of  219 
cases,  but  believes  that  many  of  these  result  from  ulcerations  caused 
by  gonorrheal  infection,  from  abscess  of  the  Bartholin  glands,  or 
from  fecal  pressure  (decubital  ulcer),  or  local  traumatism  from  the 
syringe-tip. 

Ulcers  from  gonorrhea,  traumatism,  and  hemorrhoids  occur  in 
the  rectum  and  are  referred  to  under  Proctitis.  Ulceration  of  intes- 
tinal carcinoma  may  occur,  or  metastatic  nodules  may  break  down 
and  ulcerate. 

Intestinal  Myiasis 

A  case  of  fatal  ulceration  of  the  colon  due  to  maggots  has  been 
reported." 

General  Symptoms  of  Intestinal  Ulceration 

Our  readers  must  take  into  consideration  the  special  types  of  ulcer, 
their  etiology,  and  the  history  of  the  case  in  making  the  diagnosis. 

In  some  cases  this  is  quite  difficult,  as  the  symptoms  are  not 

constant.     The  salient  diagnostic  points  of  intestinal  ulcer  are  as 

follows : 

^  Virchow's  Archiv.,  Bd.  127. 

2  Schlesinger,  Wiener  klin.  Wochenschr.,  January  9,  1901. 


552  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

1.  The  appearance  of  pus  in  the  stool.  This  is  frequently  in  small 
quantity  and  in  the  form  of  minute  grayish-white  lumps,  which  ap- 
pear under  the  microscope  as  closely  aggregated  masses  of  pus-cells, 
and  are  especially  important.     At  times  it  is  only  microscopic. 

2.  Necrotic  pieces  of  the  intestinal  mucosa,  such  as  shreds  of 
tissue  from  the  intestinal  wall,  which  must  be  differentiated  from 
membranous  or  shred-like  particles  of  food,  occur  in  some  cases. 

3.  The  appearance  more  or  less  frequently  of  blood  in  the  stool, 
unchanged  and  in  large  amount  as  pure  blood,  or  changed,  coffee- 
ground,  or  occult  blood.  In  some  cases  blood  is  only  shown  under 
the  microscope,  or  by  hematin  crystals,  or  by  Weber's  or  the  benzidin 
test.     Gastric  ulcer  and  vicarious  hemorrhage  must  be  excluded. 

4.  The  constant  appearance  of  tubercle  bacilli  in  the  stools  in 
connection  with  diarrhea  and  increasing  emaciation  are  diagnostic 
of  tuberculous  ulceration;  also  the  tuberculin  reaction. 

5.  Persistent  diarrhea  (with  local  tenderness)  and  pain  of  a  greater 
or  lesser  degree  over  a  definite  region  of  the  abdomen,  extending  over 
a  considerable  period  of  time,  associated  with  the  presence  of  pus 
and  blood  in  the  dejecta. 

6.  Tenesmus,  with  pus  and  blood  in  the  stool,  suggests  ulcer, 
probably  in  the  rectum,  and  visual  examination  makes  the  diagnosis. 

The  presence  of  mucus  is  not  diagnostic  of  ulcer. 

Diarrhea. — This  is  present  in  a  large  number  of  cases.  It  is 
dependent  on  the  site  of  the  lesions ;  ulcerations  of  the  small  intestine, 
cecum,  or  ascending  colon  probably  do  not  produce  diarrhea  unless 
there  is  a  complicating  catarrh,  amyloid  degeneration,  or  some 
special  infection  like  typhoid  fever.  Even  in  the  latter  we  have 
constipated  cases.  Ulcers  of  the  lower  colon  and  rectum  usually 
produce  diarrhea,  but  even  here  it  may  occasionally  be  absent. 

Blood. — -Pure  blood  may  be  passed  in  large  amounts  in  simple 
duodenal  ulcer  from  burns  and  in  typhoid.  Targe  hemorrhages 
at  times  occur  from  dysenteric  ulcers.  The  hemorrhages  from 
catarrhal  and  tuberculous  ulcers  are,  as  a  rule,  not  as  large. 

The  blood  may  be  bright  red  or  dark,  or  of  coffee-ground  color, 
or  may  be  only  determined  microscopically  as  blood-corpuscles  or 
hematin  crystals,  or  by  tests  for  occult  blood. 

Intestinal  ulcer  may  be  present  without  hemorrhage,  and  other 
conditions  may  produce  intestinal  hemorrhage,^  such  as  liver  cirrho- 
sis, etc. 

Pus  is  diagnostic  of  intestinal  ulcer.  It  is  also  found  in  con- 
nection with  ulceration  accompanying  neoplasms  of  the  intestines, 
and  in  abscesses  which  open  into  the  intestines.  It  is  generally  in 
small  amounts.  Occasionally  no  pus  is  found,  as  in  the  case  of 
duodenal  ulcer;  or  the  ulcer  may  be  single  and  high  up,  so  that  the 
pus  will  disappear.  If  small  grayish-white  specks  are  discovered  in 
the  stool  and  under  microscopic  examination  they  are  found  to  be 
1  Repeated  examinations,  however,  will  generally  show  occult  blood. 


ULCERS    OF   THE    INTESTINES  553 

pus,  the  diagnosis  of  ulcer  is  established.  Pus  is  often  only  found 
by  the  microscope. 

Mucus  found  mixed  with  the  intestinal  contents  is  the  result 
of  associated  intestinal  catarrh.  We  can  draw  some  conclusion  from 
the  relative  amount  of  pus,  blood,  and  mucus.  Mucus  is  never  diagnos- 
tic of  ulcer. 

Pure  pus  is  also  found  in  a  diphtheritic  process  of  the  bowel  or 
from  perforating  abscess. 

Blood,  pus,  and  mucus  occur  in  dysentery  and  in  carcinoma  of 
the  lower  colon  or  rectum. 

Shreds  of  Tissue. — They  consist  of  mucous  membrane  and  are 
differentiated  from  particles  derived  from  food;  they  occur  most 
frequently  in  dysenteric  ulcer  and  not  in  the  slower  type,  as  in 
tuberculosis;  or  in  the  more  rapid,  as  in  typhoid. 

Tubercle  Bacilli. — Generally  diagnostic  of  tuberculous  ulcer, 
in  connection  with  the  other  symptoms.  Rarely  sputum  may  be 
swallowed  and  pass  through  without  infection.  Absence  of  bacilli 
does  not  always  prove  absence  of  tuberculous  process.  The  injec- 
tion of  tuberculin  or  the  ocular  test  (conjunctival)  aid  diagnosis  in 
the  doubtful  cases. 

Pain. — This  is  occasionally  absent.  If  pain  exists  in  a  circum- 
scribed spot  for  a  long  time  and  is  increased  on  pressure,  it  is  probably 
due  to  ulcer.     It  may  at  times  be  caused  by  local  peritonitis. 

Ulcers  of  the  rectum  produce  tenesmus,  which  is  quite  charac- 
teristic.   Rectal  examination  should  always  be  made. 

Fever  is  present  in  the  tuberculous  type,  dysentery,  etc.,  but 
not  in  all  types  of  ulcer,  being  dependent  on  the  etiologic  cause. 

General  Nutrition. — This  may  not  be  disturbed  by  a  few  small 
ulcers,  but  marked  ulceration,  especially  of  the  tuberculous  type, 
leads  to  great  emaciation,  as  the  intestinal  contents  are  rapidly 
propelled  and  also  normal  absorption  is  interfered  with. 

Perforation  with  general  peritonitis,  local  peritonitis,  or  encap- 
sulated abscess  may  occur.     Stricture  may  result  from  ulcers. 

Prognosis. — ^The  prognosis  depends  on  the  etiology. 

Treatment 

Hemorrhage  should  be  treated  as  in  that  from  duodenal  ulcer. 
The  primary  cause  should  receive  appropriate  treatment;  in  uremic 
ulcers,  the  nephritis ;  in  syphilitic  ulcers,  by  hypodermics  of  bichlorid 
of  mercury;  mercurial  inunction;  protiodid,  bichlorid,  and  iodid  of 
potassium. 

Heat  or  cold  can  be  applied  for  the  pain  and  rest  in  bed  for  the 
severe  cases. 

In  tuberculous  ulceration,  out-of-door  life  and  change  of  climate 
are  important.  Beech  wood  creosote,  Ttlij  (0.118)  t.  i.  d.,  guaiacol 
carbonate,  carbonate  of  creosote,  and  creosal  (tannosal)  are  useful. 
Average  doses  of  these  remedies  are  gr.  10  (0.6)  t.  i.  d. 


554 


DISEASES    OF    THE    STOIMACH   AND    INTESTINES 


Diet  is  important;  it  should  be  non-irritating  and  chiefly  liquid, 
such  as  milk,  kumyss,  matzoon,  bacillac,  lactone-buttermilk,  raw 
eggs  beaten  in  milk;  soft-boiled  eggs,  broths,  chicken  soup,  mushes, 
etc.  Fats,  such  as  butter,  emulsion  of  mixed  fats  (Russell's),  cream, 
etc.,  are  of  value. 

Some  cases  can  take  sweetbread,  scraped  beef,  calves'  brains, 
cocoa,  tea  or  weak  coffee,  milk-toast,  etc. 

Sanatogen  (flavored)  and  malt-tropon  can  be  given  in  broths 
or  soups. 

Compound  tincture  of  catechu,  chalk  mixture,  opium,  etc.,  are 
useful  for  severe  diarrhea.     The  fohowing  are  excellent: 

I^.     Comp.  tinct.  opii  )    aa   oss  (16.0) 

Bismuth,  subnit.  J 

Mist,  cretse oij  (60.0) 

Aq.  destil q.  s.  oiv  (125.0^ — M. 

Sig. — Shake.     Dose,  oij  (8.0)  every  three  hours. 

I^.     Tr.  opii Hlx  (0.59) 

Mist,  cretse 3  j  (4-o) 

Comp.  tinct.  catechu q.  s.  3ij  (8.0). — M. 

Sig. — Dose,  5ij  (8.0).     Administer  every  three  hours. 

Bismuth  subnitrate,  gr.  15  to  30  (1.0-2.0),  three  or  four  times 
a  day,  or  bismuth  subcarbonate  or  bismuth  saHcylate,  *r.  10  to  15 
(0.6-1.0),  may  be  substituted.     Avoid  opiates  as  much  as  possible. 

Tannigen,  bismuth  subgaflate,  tannalbin,  and  tannocol  are  useful 
in  average  doses  of  gr.  10  to  15  (0.6-1.0)  three  or  four  times  a  day. 

High  injections  of  silver  nitrate,  1:3000;  thymol,  1:2000; 
salic3'Hc  acid,  1:300;  boric  acid,  1:500;  tannic  acid,  1:1000;  and 
protargol,  i  :  1000,  are  of  seri-ice  in  rectal  and  colonic  ulcers. 

CarboHc  acid  should  not  be  used,  and  bichlorid  of  mercury 
(i  :  10,000)  bv  recurrent  irrigation  only  in  typhoid  in  the  diphtheritic 
form  of  colitis.  Special  local  treatment  is  necessary  for  proctitis, 
as  already  described. 

DISEASES  OF  THE  BLOOD-VESSELS  ?  EMBOLISM  AND  THROMBOSIS 

OF  THE  MESENTERIC  ARTERIES  AND  VEINS  (INFARCTION 
OF  THE  BOWEL) 

Embolism  and  thrombosis  of  the  mesenteric  arteries  are  com- 
paratively rare  aft'ections. 

When  the  mesenteric  vessels  are  blocked  by  emboli  or  thrombi, 
infarction  follows  in  the  territory  supplied  by  the  vessel,  which  may 
continue  to  gangrene  or  perforation  and  peritonitis.  If  only  a  few 
small  vessels  are  occluded  there  may  be  few  if  any  symptoms,  and 
the  circulation  may  be  re-established.  Welch^  states  that  about 
70  cases  of  embolism  or  thrombosis  of  the  mesenteric  arteries  have 
been  published,  while  Gallavardim  has  collected  83  cases,  of  which 
63  were  of  embolism. 

1  Allbutt's  System  of  Medicine,  vol.  ii,  1S94;  also  vel.  iv. 
-Gaz.  des  Hop.,  Paris,  1901,  p.  929. 


DISEASES   OF   THE    BLOOD-VESSELS  555 

As  the  clinical  symptoms  of  obstruction  of  the  mesenteric  arteries 
and  veins  can  scarcely  be  differentiated  during  life,  the  symptoms 
being  much  the  same,  and  since  careful  study  of  their  etiology  may 
aid  in  diagnosis,  it  is  advisable  to  describe  them  together.  Including 
both  arterial  and  venous  mesenteric  obstruction,  Jackson,  Porter, 
and  Quimby  have  studied  about  30  cases  in  Boston,  and  have 
collected  214  cases  in  all. 

Etiology. — Embolism  and  Thrombosis  of  the  Mesenteric  Arteries. — 
In  a  majority  of  cases  occlusion  is  due  to  embolism  and  rarely  to 
thrombosis. 

The  chief  source  of  the  emboli  are  traceable  to  endocarditis 
(valvular  lesions)  or  atheroma  of  the  aorta,  or  rarely  from  a  pul- 
monary thrombosis  or  aneurism  of  the  aorta. 

Thrombosis. — Local  changes  in  the  vessels,  as  endarteritis 
(described  by  lyitten),  syphilitic  endarteritis,  injury  and  pressure 
from  calcareous  glands,  have  been  given  as  causes.  Rolleston 
refers  to  peri-arteritis  nodosa,  a  rare  condition  in  man,  with  the 
production  of  multiple  aneurysms,  which  produces  pain,  colic  and 
diarrhea,  with  ulceration.  The  superior  mesenteric  artery  is  more 
often  affected.  Verminous  aneurysms  cause  infarctions  in  the 
horse. 

Etiology  of  Thrombosis  of  the  Mesenteric  Veins  or  the 
Portal  Vein. — Welch^  has  collected  32  cases  and  has  demonstrated 
that  the  superior  mesenteric  vein  is  more  often  affected  than  the 
inferior  mesenteric.  Among  the  causes  are  pressure  on  the  portal 
vein,  as  in  cirrhosis  or  cancer  of  the  liver;  neoplasms  of  the  abdomen; 
chronic  peritonitis,  with  formation  of  constricting  tissue;  local 
pressure  r  incarceration  of  the  intestines ;  suppurative  inflammation 
of  the  portal  system  as  a  result  of  infection,  as  in  appendicitis, 
intestinal  ulcer,  or  dysentery.  Traumatism  may  produce  inflamma- 
tion and  thrombosis.  Mayland-  shows  that  it  may  occur  after  oper- 
ation; from  tuberculous  peritonitis,  or  diseased  mesenteric  glands. 
Hemorrhagic  infarction  of  the  intestines,  as  a  rule,  occurs  with  venous 
thrombosis,  and  the  general  symptoms  are  the  same  as  due  to  arterial 
-occlusion;  hence,  the  comparative  study  of  the  etiology  of  these 
different  conditions  is  important  for  diagnosis. 

We  would  note  that  in  a  few  rare  instances  Welch  and  Rolleston 
have  reported  exceptional  conditions;  the  former,  that  acute  portal 
obstruction  has  caused  hemorrhagic  infarction  of  the  intestines, 
without  thrombosis  of  the  mesenteric  vein ;  and  the  latter,  thrombosis 
of  both  veins  without  infarction.'' 

Pathology  of  Occlusion  of  the  Superior  Mesenteric  Artery. — 
The  changes  resulting  from  occlusion  of  this  vessel  or  its  branches 
are  hemorrhagic  infarcts  and   peritonitis.     If  only  small  branches 

1  Allbutt's  System  of  Medicine,  vol.  v. 

2  British  Medical  Journal,  1901,  vol.  ii. 

3  Rolleston,  Trans.  Patli.  Soc,  vol.  xlii. 


556  DISEASES   OE  THE    STOMACH   AND   INTESTINES 

are  occluded  the  results  are  embolic  or  thrombotic  ulcers  of  the 
intestines,  to  which  article  I  refer  my  readers. 

The  transverse  duodenum,  ileum,  jejunum,  caput  coli,  ascending 
and  transverse  colon  are  supphed  by  this  vessel,  and  lesions  of  the 
intestines  occur  in  that  portion  of  the  bowel  supplied  by  the  occluded 
branch  or  branches.  It  usually  involves  a  continuous  segment  of 
the  gut,  quite  frequently  in  the  lower  jejunum  and  ileum;  but  if 
smaller  vessels  or  branches  are  occluded,  there  may  be  lesions  scat- 
tered in  several  places  over  the  bowel,  with  healthy  segments  between 
them. 

The  superior  mesenteric  artery  has  such  long  and  small  branches 
that  it  acts  functionally,  Uke  a  terminal  artery,  so  sufficient  blood 
cannot  be  supplied  to  the  intestines  if  it  or  one  of  its  branches  be 
occluded. 

Welch  and  Mall^  have  demonstrated  experimentally  that  if  a 
branch  be  occluded,  the  blood  which  produces  the  hemorrhagic 
infarction  is  derived  from  anastomosing  arteries  and  not  from 
regurgitation  from  the  portal  vessels,   as  was  formerly  supposed. 

The  following  are  the  chnical  appearances  in  the  intestines: 
Arteries  empty,  except  at  obstruction.  There  are  venous  hyperemia ; 
edema  and  necrosis;  hemorrhages  in  the  mucous  membrane  and 
mesentery.  The  mucosa  is  a  dark  red  and  finally  becomes  necrotic, 
of  a  brownish-green  appearance.  The  intestinal  canal  contains 
extravasated  blood,  either  fresh  or  tarry  looking.  Necrosis  of  the 
intestines  is  present. 

The  serous  coat  is  inflamed,  not  only  in  the  affected  area  but 
also  over  the  healthy  intestines,  and  the  coils  may  become  adherent 
and  be  covered  with  fibrin.  There  may  be  a  blood-stained  or 
purulent  exudate  in  the  peritoneal  cavity.  Occasionally  gas  may 
be  present  in  the  cavity  due  to  the  Bacillus  aerogenes  capsulatus  or 
emphysema  of  the  mucosa. 

Clinical  Symptoms. — Kussmaul  and  Gerhardt^  first  clearly 
described  these  some  years  ago. 

There  are  two  types,  the  most  frequent  characterized  by  hemor- 
rhage from  the  intestines;  the  second,  simulating  intestinal  obstruction, 
with  or  without  peritonitis. 

Usually  the  onset  is  sudden,  frequently  with  violent,  colicky 
pains  in  the  region  of  the  umbilicus,  which  may  gradually  become 
diffuse,  and  at  the  same  time  there  is  tenderness  on  pressure  over 
the  abdomen.  We  must  remember  that  in  some  cases  there  is  an 
absence  of  pain. 

Vomiting  may  accompany  the  pain.  Diarrhea  may  begin 
shortly  after  the  pain  and  become  extreme — mucous,  watery,  and  at 
last  bloody — or  an  intestinal  hemorrhage  may  occur  at  the  com- 
mencement, with  dark-brown  or  tarry  stools,  which  at  times  may  have 

1  Johns  Hopkins  Hosp.  Reports,  vol.  i. 

2  Wiirzburger  med.  Zeitschr.,  1863  and  1864,  Bd.  iv  and  v. 


DISEASES    OF   THE    BLOOD-VESSELS  557 

a  fetid  odor.  The  blood  may  not  always  be  voided,  but  retained, 
and  the  patient  may  have  the  symptoms  of  hemorrhage — collapse, 
cold  extremities,  rapid  and  feeble  heart,  and  subnormal  tempera- 
ture. 

In  the  other  type  of  cases  the  patient  may  have  signs  of  acute 
intestinal  obstruction;  a  history  of  constipation  for  some  days; 
distended  and  painful  abdomen;  vomiting,  at  times  feculent;  severe 
abdominal  pains;  collapse  and  peritonitis.  The  attack  is  clearly 
due  to  intestinal  paralysis. 

Diagnosis. — The  following  may  be  of  service:  An  intestinal 
hemorrhage  from  no  apparent  cause;  colicky  pains  of  great  severity; 
tympanites  and  tenderness ;  evidences  of  effusion  into  the  peritoneal 
cavity;  the  discovery  of  simultaneous  embolism  in  other  vessels  or 
of  an  endocarditis.  In  many  cases,  however,  the  salient  symptoms 
are  not  all  present;  and  in  the  type  simulating  obstruction  the  true 
cause  cannot  be  determined. 

Prognosis. — ^This  is  generally  fatal  in  occlusion  of  the  superior 
mesenteric  artery.     In  rare  instances  recovery  may  be  possible. 

Treatment  will  be  described  at  the  end  of  the  chapter. 

Embolism  and  Thrombosis  of  the  Inferior  Mesenteric  Artery. 
— In  83  cases  of  Gerhardt,  in  only  5  instances  was  the  inferior  mesen- 
teric artery  obstructed ;  in  4  cases  by  emboli  and  in  i  by  thrombosis ; 
and  in  2  of  these  the  superior  mesenteric  artery  was  also  obstructed. 
This  condition  is  rare. 

Symptoms. — ^The  chief  symptoms  are  pain,  tenesmus,  and  bloody 
stools.  Gerhardt  states  that  the  blood  is  bright  red  and  that  in  ob- 
struction of  the  superior  vessel  it  is  darker,  but  I  believe  it  generally 
dark.  The  descending  colon,  sigmoid,  and  rectum,  or  parts  of  these 
are  affected,  the  mucosa  becoming  red,  succulent,  and  containing 
effusions  of  blood.  The  mucous  membrane  may  be  loose  and  de- 
tached in  places  and  hemorrhagic.  There  are  not  the  serious  lesions, 
as  a  rule,  as  in  occlusion  of  the  superior  mesenteric  artery.  The 
artery  (inferior  mesenteric)  is  not  an  end  artery  functionally,  and 
the  circulation  is  generally  re-established.  Rarely  there  may  be 
infarction  or  gangrene  with  perforation. 

Thrombosis  of  the  Mesenteric  Veins  or  Portal  Vein. — This 
condition  is  extremely  serious. 

Anatomic  Findings. — ^The  arteries  are  distended  (thus  differing 
from  the  superior  mesenteric  artery  obstruction) ;  thrombotic 
processes  are  found  in  the  mesenteric  vein  or  branches  or  in  the 
portal  vein.  The  intestines  show  similar  conditions  to  obstruction 
of  the  arteries — infarction,  necrosis,  hemorrhage,  peritonitis,  etc. 

Symptoms. — The  clinical  picture  may  present  the  same  t}'pe  as 
in  obstruction  of  the  mesenteric  arteries — colicky  pains,  tenderness, 
blood,  diarrheal  movements,  etc.  Rarely  there  may  be  hematemesis 
and  occasionally  constipation.  The  etiology,  such  as  appendicitis, 
diseases  of  the  liver  causing  pressure  on  the  portal  vein,  abdominal 


558  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

neoplasms  or  constricting  bands,  producing  pressure,  etc.,  and  the 
exclusion  of  the  causes  of  embolism,  may  aid  our  diagnosis. 

Treatment. — Temporarily,  ice-bag  to  abdomen;  stimulants,  mor- 
phin,  gr.  \  (0.016),  and  ernutin,  Hlv  (0.296),  by  hypodermic;  gelatin 
solution,  calcium  chlorid,  or  lactate  of  calcium  to  check  hemor- 
rhage, as  described  in  Dysentery. 

Immediate  resort  to  laparotomy  and  resection  of  the  diseased  area 
is  indicated,  if  possible.  Cases  of  recovery  after  this  procedure  have 
been  reported.  ElHott  resected  48  inches  of  intestines  in  one  case 
with  recovery. 


CHAPTER  XXVII. 
NEOPLASMS  OF  THE  INTESTINES 

MALIGNANT  GROWTHS 

{Synonym. — Neopiasmata  Maligna  Intestini.) 

Though  many  have  claimed  that  intestinal  cancer  is  a  com- 
paratively rare  disease,  recent  statistics  show  that  it  has  increased 
in  frequency  and  is  more  common  than  has  been  generally  supposed. 

Among  the  malignant  tumors  met  with  in  the  intestines,  car- 
cinoma is  by  far  the  commonest.  Sarcoma  and  lymphosarcoma  are 
also  found,  and  will  be  described  in  a  separate  section. 

CARCINOMA  OF  THE  INTESTINES 

Etiology. — ^The  cause  of  intestinal  cancer,  like  that  of  cancer 
of  other  organs,  is  still  unknown.  There  have  been  many  theories 
advanced,  such  as  the  embryonal  origin,  parasitic  infection,  the 
theory  of  irritation,  etc.  The  traumatic  theory  (irritation  as  the 
cause),  in  so  far  that  it  might  hasten  the  development  of  the  con- 
dition, is  afforded  a  certain  amount  of  plausible  support,  in  view  of 
the  fact  that  the  disease  occurs  most  frequently  in  those  parts  of 
the  bowels  in  which  the  feces  are  retarded,  and  hence  act  as  a  source 
of  irritation.  The  points  of  selection  for  the  development  of  cancer 
are  the  same  as  those  in  which  the  so-called  decubital  or  stercoral 
ulcers  most  frequently  develop,  and  we  may  assume  they  probably 
originate  from  the  cicatricial  tissue  of  these  ulcers,  in  some  cases  at 
least,  or  on  the  base  of  other  ulcers. 

Billroth  has  found  a  carcinoma  in  the  scar  of  a  dysenteric  stric- 
ture, just  as  it  occurs  in  the  case  of  carcinoma  engrafted  on  the  scar 
of  a  stomach  ulcer.  It  will  probably  eventually  be  shown  to  be  due 
to  some  specific  organism  in  my  opinion. 

Sex. — Carcinoma  of  the  intestines  appears  to  be  somewhat  more 
common  in  men  than  in  women. 

Age. — In  general  this  lesion  is  most  common  between  the  fortieth 
and  sixty-fifth  year. 

Contrary  to  cancer  developed  in  other  regions,  cancer  of  the 
intestines  has  been  encountered  quite  frequently  before  the  fortieth 
year.  It  has  been  found  even  in  children ;  several  cases  being  reported 
at  the  ages  of  eleven  to  seventeen,  and  2  cases  in  children  of  three 
years  of  age. 

Maydl,  of  Vienna,  has  calculated  from  records  that  one-sixth  of 
all  cases  of  intestinal  carcinoma  occur  between   thirty  and   forty 

559 


560  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

years,  and  one-seventh  before  the  thirtieth  year.  It  is  important 
to  remember  that  early  occurrence  is  fairly  frequent. 

Situation  of  the  Carcinoma. — Cancer  of  the  bowel  is  rare  in 
the  small  intestine,  occurs  quite  frequently  in  the  colon,  and  most 
commonly  in  the  rectum. 

From  1882-93,  from  autopsies  in  the  Vienna  General  Hospital, 
Riegel  states  5  cases  were  in  the  duodenum;  6  in  the  ileum;  none 
in  the  jejunum;  i  in  the  vermiform  appendix;  14  in  the  cecum;  63 
in  the  colon;  40  in  the  sigmoid,  and  114  rectal  cancers. 

At  the  same  hospital,  during  twelve  years,  out  of  254  cases  of 
cancer  of  the  intestines,  Maydl  found  in  the  living  that  224  were 
cancer  of  the  rectum. 

Bryant,  in  no  autopsies,  found  carcinoma  of  the  small  intestine 
6  times;  7  times  in  the  cecum  and  ileocecal  region;  19  times  in  the 
transverse  colon,  including  its  flexures;  78  times  in  the  sigmoid 
flexure  and  rectum. 

Leichtenstern's  data  show  that  80  per  cent,  of  all  intestinal 
cancers  occur  in  the  rectum. 

Other  statistics  are  given.  They  all  show  the  preponderance  of 
rectal  cancer. 

Intestinal  cancers  are  almost  always  primary,  and  secondary 
growth  by  metastasis  is  extremely  rare. 

It  may  occur  through  direct  extension  by  continuity,  as  a  cancer 
of  the  pancreas  may  extend  to  the  intestines. 

Primary  carcinomata  of  the  intestines  often  give  rise  to  metastases 
in  other  organs.  These  are  most  frequently  found  in  the  lymph- 
glands,  especially  in  the  neighborhood  of  the  neoplasm. 

Secondary  metastases  in  the  liver  are  quite  frequent,  no  matter 
where  the  situation  of  the  carcinoma.  The  peritoneum,  omentum, 
mesentery,  and  lungs  may  be  involved,  and  occasionally  the  kidneys. 

Hauser  calls  attention  to  certain  peculiarities  regarding  the 
metastases  in  different  forms  of  carcinoma  of  the  large  intestine. 
Colloid  carcinoma  chiefly  involves  the  serous  coat  and  metastases  of 
internal  organs  are  rare.  Medullary  tumors  involve  adjacent 
lymph-glands,  while  simple  and  scirrhous  carcinomata,  even  when 
small,  frequently  cause  carcinoma  of  the  liver. 

Morbid  Anatomy. — Several  varieties  of  carcinoma  are  found 
in  the  intestines,  most  often  the  cylindric  epithelial-celled  carcinoma 
(adenocarcinoma),  starting  in  the  cylindric  epithelium  of  the  intes- 
tinal glands  (follicles  of  lyieberkiihn).  It  occurs  most  frequently  in 
the  large  intestine,  as  do  medullary  carcinoma  and  colloid  cancer. 
More  rarely  the  scirrhous  carcinoma  is  found.  The  epitheliomatous 
chancroid  occurs  in  the  lower  rectum  at  the  anus,  and  it  may  involve 
the  perineum  and  vagina. 

In  the  small  intestine  the  primary  proliferation  starts  from  the 
glands  of  Brunner;  in  cases  developing  from  cicatrices,  proliferation 
may  start  from  glandular  tubules  which  have  grown  deep  down  into 


NEOPLASMS    OF    THE    INTESTINES  561 

the  tissue.  The  growth  varies  in  consistency,  depending  upon 
whether  connective  tissue  or  cells  predominate;  if  the  former,  then 
the  tumor  presents  a  hard  consistence  (scirrhous) ;  and  if  the  latter 
then  it  is  less  firm  and  occasionally  soft  and  succulent.  The  colloid 
cancer  contains  a  brown  viscid  fluid.  The  scirrhous  show  a  tendency 
to  ulcerate. 

The  cancer  may  form  a  hard  annular  induration,  as  in  the  colon, 
or  a  circumscribed  nodule  or  an  ulcerating  gangrenous,  cauliflower 
growth,  as  in  the  rectum.  The  nodule  may  develop  into  a  single 
large  tumor  or  several  smaller  masses;  the  softer  tumors  usually 
grow  to  larger  size.  At  other  times  the  mass  may  protrude  into  the 
intestines,  like  a  poh'pus;  or  may  infiltrate  a  large  surface  of  the 
bowel,  so  that  it  becomes  stiff  and  rigid. 

In  the  majority  of  intestinal  carcinomata  the  surface  is  ulcerating. 

The  annular  form  of  the  growth  is  most  common,  tending  to 
involve  the  circumference  of  the  bowel.  It  may  develop  from  a 
small  nodule  or,  more  frequently,  on  the  base  of  an  old  annular 
cicatrix,  due  to  former  ulceration. 

Stenosis  of  the  canal  is  often  the  result. 

Secondary  changes  develop ;  the  intestines  become  dilated  through 
stagnating  feces  and  gas,  and  the  walls  hypertrophied  above  the 
stenosis  through  overexertion  to  overcome  the  obstacle.  Catarrhal 
inflammation  and  stercoral  ulcers  develop  in  the  dilated  portion  of 
the  gut  and  perforation  may  ultimately  occur. 

Below  the  stricture  the  intestinal  walls  are  thinner,  and  if  the 
stenosis  is  narrow,  the  intestines  may  be  empty  and  contracted. 

Stenosis  of  the  bowel  may  be  produced  by  a  growth  of  the  cancer 
into  its  lumen  or  by  infiltration  of  the  entire  wall. 

Large  masses  of  very  hard  scybalse  often  accumulate  above  the 
seat  of  obstruction  and  are  difficult  to  distinguish  from  the  carci- 
noma proper,  so  that  on  autopsy  a  small  growth  may  be  found  which 
intra  vitam  was  believed  to  be  of  large  size. 

When  stenosis  of  the  bowel  occurs,  all  the  symptoms  are  present 
which  are  described  under  this  condition. 

Narrowing  of  the  bowel  does  not  always  take  place.  Sometimes 
"the  symptoms  of  stenosis  may  gradually  disappear,  being  due  to 
ulceration  of  the  neoplasm,  so  that  the  canal  again  becomes  patent. 
As  a  rule,  it  tends  to  grow  and  fill  up  again. 

The  necrotic  process  often  causes  more  or  less  hemorrhage,  and 
in  rare  cases,  if  a  large  vessel  is  eroded,  there  may  be  a  fatal  issue. 
The  canal  may  become  patent  by  a  direct  connection  becoming 
established,  through  ulceration  and  adhesions,  between  two  loops  of 
the  intestines. 

The  muscular  and  serous  coats  are  frequently  involved,  and 
peritoneal  adhesions  develop  which  may  unite  the  diseased  intestines 
to  other  portions  of  the  intestines,  or  to  some  adjacent  organ,  which 
may  constitute  a  serious  obstacle  to  the  removal  of  the  growth. 

36 


562  DISEASES   OE  THE   STOMACH  AND  INTESTINES 

Perforation  may  rarely  occur  before  the  formation  of  adhesions,  with 
resulting  general  peritonitis,  or  there  may  be  a  circumscribed  abscess 
formed  within  the  adhesions.  Marked  displacement  of  the  intestines 
may  be  caused  by  the  formation  of  these  adhesions. 

A  carcinomatous  peritonitis  may  be  produced  by  extension  from 
the  serous  layer  of  the  intestines,  accompanied  by  hemorrhagic 
exudation.  Perforation  into  other  organs  which  have  become 
agglutinated  to  the  bowel  can  occur;  thus  a  fistulous  opeiling  forms 
between  the  colon  and  the  stomach  or  bladder,  or  vagina  or  uterus, 
or  between  the  large  and  small  intestines,  or  from  the  bowel  through 
the  abdominal  wall. 

The  omentum  and  mesentery  may  become  infiltrated  with 
cancerous  masses.  A  band  may  be  formed  by  the  stiffened  omentum, 
which  may  cause  a  knuckling  or  a  twisted  bowel.  The  mesentery 
may  kink  and  twist  the  intestines. 

Sjmiptoms. — ^The  symptoms  vary,  depending  on  the  position  of 
the  neoplasm,  the  rapidity  of  its  growth,  and  the  character  of  the 
cancer.  There  may  be  symptoms  at  first  of  habitual  constipation 
or  of  hemorrhoids,  or  of  stenosis  of  the  intestines,  or  of  peritonitis,  or 
icterus,  or  of  cachexia  of  uncertain  origin.  It  seems  preferable  to 
first  review  the  general  and  then  the  local  symptoms,  depending 
upon  the  position  of  the  tumor,  as  occurring  with — 

1.  Carcinoma  of  the  duodenum. 

2.  Carcinoma  of  the  small  intestine. 

3.  Carcinoma  of  the  colon  (cecum  to  sigmoid  flexure). 

4.  Carcinoma  of  the  rectum. 

General  S5rmptoms. — There  are  symptoms  common  to  all  cases 
of  carcinoma,  of  which  anemia  and  cachexia  are  the  most  important. 
As  a  rule  they  occur  together,  though  one  may  develop  before  the 
other.  In  many  patients  weakness,  pallor,  and  emaciation  are  the 
first  signs  noticed,  and  arouse  the  suspicion  of  a  serious  disease. 
There  may  be  only  slight  local  symptoms,  moderate  constipation, 
and  a  sense  of  weight  or  discomfort  in  the  abdomen,  with  loss  of 
appetite,  coated  tongue,  and  slight  dyspeptic  disturbances.  There 
is  loss  of  weight  and  a  peculiar  cachectic  appearance.  On  the  other 
hand,  the  local  symptoms  may  be  the  more  pronounced,  or  the  local 
and  general  symptoms  may  occur  together. 

Quite  frequently,  especially  in  those  cases  of  carcinoma  which 
run  a  rapid  course,  fever  is  present.  I  have  seen  a  number  of  cases 
in  which  it  is  entirely  absent.  It  probably  depends  upon  an  ulcera- 
tive condition  in  the  growth  and  absorption  of  toxic  products. 
The  tumor  may  cause  symptoms  in  adjacent  organs  by  dragging 
upon  them  or  constricting  them.  There  may  be  radiating  pains 
from  compression  of  nerves  and  also  disturbances  of  the  circulation, 
such  as  edema  of  the  lower  extremities. 

Symptoms  of  chronic  intestinal  obstruction  are  frequently  pres- 
ent, but  not  in  all  cases.     The  symptoms  may  develop  gradually, 


NEOPLASMS   OF   THE)    INTESTINES  563 

the  constipation  increasing,  or  there  may  be  a  sudden  stoppage,  with 
all  the  signs  of  acute  obstruction.  The  clinical  symptoms  of  can- 
cerous obstruction  are  similar  to  those  from  stenosis  of  the  intestines 
caused  by  other  processes,  and  are  described  in  Chapter  XXXI. 

When  acute  obstruction  suddenly  occurs  during  the  course  of 
chronic  stenosis  a  fatal  result  may  ensue  within  a  few  days.  Fecal 
retention  has  been  reported  in  connection  with  malignant  stenosis, 
lasting  even  over  eighty  days^  without  the  presence  of  fecal  vomiting. 
Diarrhea  is  fairly  frequent  in  carcinoma  of  the  intestines.  It  is  of 
assistance  in  clearing  up  the  commencing  obstruction,  and  in  some 
cases  alternates  with  constipation. 

In  some  patients  the  stools  appear  as  small  hard  balls,  cylindric, 
like  a  pencil,  or  fiat  and  tape-Hke,  as  if  they  had  passed  a  strictured 
point.  These  are  not  always  characteristic,  as  they  may  appear 
with  nervous  conditions. 

The  stools  frequently  contain  pus,  blood,  and  mucus.  The 
appearance  of  the  first  two  (pus  and  blood)  is  significant.  If  the 
growth  is  ulcerating  markedly,  the  stools  have  a  most  offensive  odor. 
In  this  event  particles  of  tumor  may  rarely  be  found  in  the  dejecta, 
which  show  under  the  microscope  the 'nature  of  the  growth.  They 
may  be  of  fair  size  or  very  small,  so  that  careful  examination  of  the 
fecal  matter  may  be  necessary  in  order  to  find  them.  Irrigation  of 
the  bowel  is  of  assistance  if  the  neoplasm  is  situated  in  the  large 
intestine. 

One  of  the  most  important  factors  in  our  diagnosis  is  the  detec- 
tion of  the  physical  signs  of  a  tumor. 

The  growth  is  from  the  size  of  a  walnut  to  that  of  a  child's  head. 
It  is  often  easily  palpable,  hard,  and  usually  has  an  uneven  nodular 
surface. 

A  marked  peculiarity  of  this  type  of  tumor  is  its  great  mobility 
under  the  palpating  hand  of  the  examining  physician.  Even  in  the 
cecum  and  ascending  and  descending  colon  the  tumor  is  distinctly 
movable  as  a  rule.  The  mass  is  usually  situated  in  the  lower  half  of 
the  abdomen,  most  frequently  in  the  lower  left  iUac  region,  as  unless 
there  are  marked  adhesions,  the  intestines  are  dragged  down  there 
by  their  own  weight.  If  the  growth  is  in  the  cecum,  the  right  iUac 
region  is  involved. 

I  have  already  referred  to  the  fact  that  on  autopsy  the  tumor  is 
frequently  found  to  be  smaller  than  it  was  apparent  to  palpation, 
this  being  due  to  the  thickening  of  the  gut  above  the  stenosis  and  to 
the  fecal  accumulation. 

Abdominal  pain  is  present,  which  will  be  described  under  Local 
Symptoms,  and  the  tumor  is  at  times  tender. 

In  some  cases  simple  abdominal  palpation  is  not  sufficient,  and 
it  may  be  necessary  to  examine  the  patient  under  an  anesthetic. 
In  every  case  digital  examination  of  the  rectum  and,  if  necessary, 
1  Cooper-Foster,  Med.  Times  and  Gazette,  Sept.,  1867. 


564  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

the  passing  of  a  rectal  bougie  or  introduction  of  a  speculum  should 
be  employed.  In  women  a  vaginal  examination  should  also  be  made. 
I  strongly  deprecate  the  insertion  of  the  entire  hand  into  the  rectum 
under  anesthesia,  as  has  been  sometimes  advised. 

When  the  cancer  is  fully  developed  we  may  have  peritonitis, 
either  local  or  general,  as  a  complication.  If  the  peritonitis  is  of  a 
cancerous  nature,  a  hemorrhagic  exudation  and  the  presence  of 
nodules  under  the  abdominal  wall  will  indicate  this  fact.  Acute 
perforative  peritonitis  will  be  indicated  by  the  usual  symptoms  of 
this  condition.  On  the  other  hand,  we  may  have  circumscribed 
adhesions  with  the  presence  of  local  fecal  abscess. 

Perforation  may  occur  into  adjacent  adherent  organs  which  will 
present  special  symptoms. 

Among  the  chief  communications  are : 

1.  Communication  between  the  colon  and  stomach.  There  may 
be  a  valvular  communication  or  it  may  be  free.  If  the  direction  of 
the  passage  is  from  the  stomach  into  the  colon,  symptoms  of  lientery 
develop — undigested  food,  such  as  rice,  potatoes,  meat,  etc.,  appear 
rapidly  in  the  stools.  Diarrhea  occurs  shortly  after  the  ingestion 
of  food  with  evacuation  of  solid  contents.  If  the  valvular  action  is 
in  the  opposite  direction,  feculent  vomiting  takes  place.  If  the 
fistulous  opening  is  perfectly  free,  then  lientery  and  fecal  vomiting 
occur  together  or  may  alternate.  This  combination  of  s5^mptoms 
is  pathognomonic.  Lavage,  especially  if  the  fluid  be  colored  with 
methylene-blue  or  carmin,  gr.  3  (0.194),  will  demonstrate  that  the 
liquid  rapidly  escapes  from  the  stomach,  and  is  expelled  from  the 
bowel  without  being  decolorized  or  discolored. 

If  the  rectum  is  inflated  with  air  or  CO2  the  stomach  will  be 
distended  with  gas,  or  after  injection  of  i  to  2  liters  (quarts)  of 
colored  fluid  into  the  bowel  some  can  be  secured  from  the  stomach 
by  aspiration. 

2.  Communication  between  the  rectum  and  bladder.  Fecal  matter 
and  gas  escape  into  the  bladder  and  are  voided  through  the  urethra. 
Severe  septic  cystitis  results,  or  the  urine  may  escape  from  the 
bladder  and  be  discharged  through  the  stools.  A  carmine  solution 
injected  into  the  rectum  or  bladder  will  demonstrate  the  condition, 
and  will  appear  respectively  in  the  urine  or  feces. 

3.  Communication  between  the  rectum,  uterus,  and  vagina  are 
also  met  with,  and  give  rise  to  the  passage  of  fecal  matter  through 
these  organs,  and  also  to  severe  infiammatidn.  Injection  of  weak 
carmin  solution  or  methylene-blue  into  the  rectum  will  demonstrate 
the  communication. 

4.  Communication  between  the  bowel  and  abdominal  wall. 
There  may  be  a  feculent  or  fetid  discharge,  or  even  of  particles  of 
fecal  matter,  if  the  communication  is  with  the  lower  small  or  large 
intestines.  If  the  communication  is  high  up,  it  may  be  chylous  or 
biliary.     This  condition   appears  usually  in   the  last   stage  of  the 


NEOPLASMS    OF   THE    INTESTINES  565 

disease.  Injection  of  carmin  red  solution  through  the  fistula  will 
appear  in  the  stool.  Ulcerative  processes  (tubercular)  may  produce 
similar  communication. 

The  urine  is  not  characteristic,  shows  indican,  occasionally  acetone 
and  diacetic  acid.  Albumin  is  present.  Secondary  anemia  occurs. 
Leukocytosis  is  moderate  and  eosinophiles  are  increased. 

Symptoms  Due  to  Position  of  the  Cancer. — Cancer  of  the 
Duodenum. — ^This  is  a  rare  condition.  There  are  the  anemia  and 
cachexia  and  pain  usually  in  the  right  hypochondriac  region;  this 
last  occurs  in  the  midepigastric  region  or  upper  part  of  abdomen. 
The  tumor,  when  palpable,  is  usually  found  in  the  right  hypochon- 
driac region,  near  the  middle  line.  If  it  is  in  the  ascending  part  of 
the  duodenum,  there  may  be  fair  mobility;  if  in  the  descending  or 
transverse  parts,  the  tumor  is  only  slightly  movable. 

Nearly  all  the  symptoms  are  referred  to  the  stomach — anorexia, 
pains,  belching,  vomiting,  and  dilatation  of  the  stomach — and  if 
the  mass  is  in  the  ascending  part  of  the  duodenum,  it  will  hardly  be 
possible  to  differentiate  it  from  gastric  tumor  without  operation. 
Blood  may  be  mixed  with  the  vomitus. 

Boas  makes  use  of  the  terms  suprapapillary,  infrapapillar}^,  and 
circumpapillary  carcinoma,  according  to  the  position  of  the  gro\\i:h 
relative  to  the  papilla  of  Vater. 

If  the  carcinoma  is  suprapapillary,  we  have  stenosis  of  the  upper 
part  of  the  duodenum,  and,  as  already  noted,  symptoms  identical 
with  pyloric  stenosis,  from  which  it  can  hardly  be  differentiated. 

With  infrapapillary  carcinoma  the  gastric  symptoms  again 
predominate,  but  there  is  stasis  of  bile  and  pancreatic  juice,  and 
regurgitation  of  these  secretions  into  the  stomach;  bilious  vomiting 
is  frequent.  The  vomiting  is  intermittent  and  the  symptoms  those 
of  obstruction.  Trypsin  should  be  tested  for  in  the  vomit  by  observ- 
ing whether  fibrin  is  digested  in  an  alkaline  solution.  This  would 
differentiate  from  a  gastrohiliary  fistida. 

Circumpapillary  carcinoma.  In  the  pure  cases  surrounding  the 
papilla  of  Vater,  jaundice,  anemia,  and  cachexia  slowly  increase  in 
severity,  without  any  gastro -intestinal  symptoms,  and  pain  is  usually 
absent. 

Chills  may  at  times  occur  and  cholangitis  may  be  a  complication. 
Jaundice  may  vary  in  intensity  or  may  be  intermittent.  When 
the  tumor  involves  the  common  bile-duct  and  head  of  the  pancreas 
jaundice  is  progressive  and  continuous.  Ulceration  may  temporarily 
open  a  passage  for  the  bile.     Gastric  symptoms  ma>'  occur  in  addition. 

The  tumor  can  be  palpated  deep  down  in  the  right  hypochondriac 
region  near  the  middle  line.     At  times  it  cannot  be  discovered. 

Carcinoma  of  the  duodenum  is  a  disease  of  late  middle  or  advanced 
life,  most  often  in  males. 

The  second  part  of  the  duodenum  is  most  frequently  involved, 
and  next  in  frequency  the  first  part. 


566  DISEASES   OF   THE    STOMACH   AND    INTESTINES 

Carcinoma  of  the  small  intestine  (jejunum  and  ileum)  is  rare. 
The  symptoms  vary,  depending  on  the  position  of  the  growth;  the 
higher  up,  the  more  marked  are  the  gastric  s)Tiiptoms;  the  lower 
down,  the  more  severe  the  intestinal  symptoms. 

There  may  be  anorexia  and  vomiting,  or  fair  appetite  and  good 
stomach  digestion,  but  obstinate  constipation. 

In  both  conditions  there  are  anemia  and  cachexia,  pain,  attacks 
of  colic  and  constipation,  which  may  alternate  with  a  diarrhea. 
There  may  occasionally  be  hemorrhages  from  the  bowel  if  the  growth 
is  low  down.  The  clinical  S3Tiiptoms  of  stenosis  of  the  intestines  may 
be  present.  The  tumor  is  at  times  accessible  to  palpation,  and  is, 
as  a  rule,  extremely  movable.  It  may  be  so  much  displaced  down- 
ward that  it  is  difficult  to  draw  an  accurate  conclusion. 

Local  Symptoms  of  Carcinoma  of  the  Large  Intestine. — 
Cachexia  and  anemia  are  present.  Pain  is  a  frequent  symptom;  it 
may  not  be  present  at  first,  usually  appears  later  in  the  disease,  and 
becomes  localized;  in  some  cases,  running  an  acute  course,  no  pain 
appears  until  the  symptoms  of  acute  obstruction  begin.  Pain  is 
usually  localized ;  it  may  appear  near  or  at  the  region  of  the  growth, 
or  occasionally  directly  opposite,  in  the  abdomen. 

The  pain  may  not  be  severe,  but  may  be  more  a  sense  of  dis- 
comfort. There  may  be  neuralgia  of  the  sciatic  or  anterior  crural 
nerves.  Later  pain  usually  becomes  localized,  and  is  increased  on 
pressure,  even  if  the  tumor  cannot  be  palpated.  It  may  be  due  to 
local  peritonitis  near  the  tumor. 

Attacks  of  colic  often  occur,  local  or  diffuse.  The  pains  may  be  quite 
severe,  are  accompanied  with  constipation,  and  arereHeved  by  diarrhea 
or  bv  the  passage  of  flatus.  These  attacks  of  colic  are  frequently  caused 
by  the  commencing  obstruction,  and  show  gradually  progressive  steno- 
sis. Peristaltic  and  tetanic  movements  of  the  intestines  are  often 
associated.  Complete  obstruction  may  suddenly  develop,  or  there 
may  be  a  gradually  progressive  stenosis  with  its  symptoms. 

Constipation  is  one  of  the  marked  symptoms;  in  some  cases  it 
may  be  the  first,  and  becomes  gradually  progressive. 

Ten  to  twenty  or  even  eighty-eight  days  have  passed,  according 
to  various  observers,  before  the  bowels  moved  spontaneously  or  by 
artificial  means.  These  were,  of  course,  extreme  cases.  The  majority 
of  patients  have  symptoms  of  commencing  or  complete  obstruction 
after  coprostasis  has  lasted  a  week  or  ten  days.  This  has  been  my 
experience  in  consultation  practice.  Recently  I  saw  a  case  for  the 
first  time  on  the  fourth  day  of  coprostasis  when  acute  symptoms  were 
present.  Loss  of  appetite,  tension,  fulness  in  the  abdomen,  and  pain 
accompany  the  constipation.  Spontaneous  diarrhea  may  relieve  the 
condition.  If  this  does  not  occur,  or  relief  is  not  afforded  artificially, 
gradual  occlusion  will  take  place  with  its  typic  symptoms. 

In  some  patients  diarrheal  movements  may  occur  for  several 
weeks  due  to  the  catarrhal  condition  of  the  bowel. 


NEOPLASMS   OF   THE   INTESTINES  567 

Stools. — In  some  cases  of  carcinoma  the  stools  may  be  normal 
and  simply  hard  in  character  when  constipation  is  present. 

In  others  they  may  be  in  small  balls  like  sheep's  dung,  flattened, 
or  ribbon  shaped. 

Mucus  shows  the  presence  of  catarrh  of  the  mucous  membrane. 
The  presence  of  pus  in  the  stools  is  of  importance,  but  only  appears 
when  the  growth  ulcerates;  hence  its  absence  does  not  prove  there 
is  no  tumor.     Microscopic  examination  for  pus  is  indicated. 

Pus  in  some  cases  may  be  derived  from  an  abscess-cavity  opening 
into  the  intestines. 

The  same  remarks  hold  true  of  blood,  the  amount  found  is 
usually  small,  and  violent  hemorrhages  are  rare. 

The  appearance  of  pus  and  blood  in  the  stool  in  a  patient  with 
symptoms  of  stenosis  of  the  bowel  favors  the  diagnosis  of  malig- 
nancy.    Occult  blood  should  be  tested  for  if  none  is  visible. 

If  there  is  gangrenous  disintegration  of  the  tumor,  the  odor  is 
very  characteristic,  and  occasionally  small  bits  of  new  growth  may 
be  found  in  the  stool. 

Tumor. — The  presence  of  palpable  tumor  strengthens  the  diagno- 
sis. It  may  be  no  larger  than  a  nut,  or  the  size  of  a  child's  head,  and 
be  soHd  and  hard  like  cartilage.  If  there  is  much  infiltration,  it  may 
give  the  sensation  of  a  solid  and  thick  cord.  These  tumors  are 
generally  moderately  tender  on  pressure,  in  some  cases  quite  so; 
occasionally  they  are  not  tender  at  all.  Their  great  mobility  is  char- 
acteristic. On  palpation  they  are  easily  moved  about,  especially  in  the 
sigmoid  and  transverse  colon ;  fecal  accumulation  readily  displaces  the 
tumor  and  it  may  become  adherent  in  an  abnormal  position.  Occa- 
sionally peristaltic  movements  may  cause  it  to  appear  and  disappear 
during  palpation.  Respiratory  mobility  of  the  tumor  also  may  occur 
if  it  be  in  the  transverse  colon,  or  if  it  be  adherent  to  the  liver, 
spleen,  or  stomach. 

Large  amounts  of  fecal  material  may  accumulate  above  the 
growth,  and  we  must  clear  this  material  out  by  irrigation  and  laxa- 
tives, so  as  to  determine  the  extent  of  the  tumor. 

A  pure  fecal  tumor  may  lead  to  narrowing  and  occlusion.  These 
last  tumors  are  more  doughy,  less  firm,  and  quite  frequently  multiple. 
Differential  Diagnosis, — We  must  remember  that  old,  agglu- 
tinated masses  from  recurrent  appendicitis  may  simulate  cecal  tumor. 
The  history  is  an  aid.  Moreover,  tumor-like  tuberculosis  of  the 
cecum  may  simulate  malignant  growth.  In  these  cases  there  may 
be  pulmonary  tuberculosis,^ a  previous  history  of  diarrhea,  or  the 
presence  of  tubercle  bacilli*  in  the  stools.  Some  cases  cannot  be 
differentiated.     The  tuberculin  test  aids  diagnosis. 

Leube  called  to  our  attention  that  chronic  inflammation  of  the 
sigmoid  may  occur  and  be  mistaken  for  carcinoma.  Undoubtedly 
these  cases  are  so-called  peridiverticulitis,  with  chronic  thickening, 
and   often   stenosis   of   the   sigmoid   simulating  carcinoma.     These 


568  DISEASES   OF  THE   STOMACH  AND   INTESTINES 

patients  are  general!}^  over  sixty  years  of  age,  fat  and  flabby,  or 
they  have  been  fat  previous  to  emaciation.  There  is  often  a  history 
of  acute  left-sided  inflammation  and  generally  of  prolonged  constipa- 
tion. One  must  remember  the  possibility  of  this  condition.  Blood 
and  pus,  as  a  rule,  are  absent  from  the  stools  in  these  patients.  Often 
it  is  impossible  to  differentiate  these  conditions,  even  after  resection, 
except  by  the  microscope. 

Cachexia  and  anemia  are  always  present  in  cancer. 

Primary  Carcinoma  of  the  Appendix. — This  is  rare;  most  of 
the  cases  give  svmptoms  of  relapsing  appendicitis  or  appendicitis; 
53  per  cent,  are  under  thirty  years,  and  24  per  cent,  under  twenty. 
This  condition  has  only  been  detected  after  operation  on  the  appen- 
dix.    The  carcinoma  is  spheroidal  celled. 

Carcinoma  of  the  Rectvun. — This  is  the  most  frequent  type  of 
cancer,  is  more  readily  diagnosed,  and  more  amenable  to  treatment 
if  early  operation  is  performed.  Many  of  the  tumors  are  within 
reach  of  the  finger.  The  symptoms  resemble  those  of  carcinoma  of 
the  colon,  though  there  are  certain  signs  peculiar  to  this  condition. 
Rectal  examination  should  always  be  made. 

Pain  is  more  pronounced  in  rectal  carcinoma,  both  local  and 
radiating  to  the  sacrum,  back,  bladder,  genitals,  and  to  the  sciatic 
nerve ;  there  is  often  a  desire  to  urinate.  The  pain  is  usually  worse 
during  defecation  if  the  growth  is  low  down,  and  it  may  even  be 
agonizing  in  character,  so  much  so  that  the  patients  try  to  retain 
the  bowel  contents  as  long  as  possible. 

Marked  tenesmus  is  present,  and  if  ulceration,  mucus,  blood,  and 
pus  are  evacuated.  Constipation  is  usually  present.  The  higher 
up  in  the  rectum,  the  more  the  symptoms  resemble  those  of  cancer 
of  the  sigmoid.  Diarrhea  may  at  times  supervene;  occasionally 
after  sloughing  of  the  tumor,  paralysis  of  the  sphincter  occurs. 

Leube  was  the  first  to  call  attention  to  the  fact  that  hemorrhoids 
frequently  developed  with  carcinoma  of  the  rectum,  and  that,  too,  at  an 
early  stage.  Piles  occurring  suddenly,  and  not  developing  slowly 
or  existing  for  many  years,  are  suggestive. 

Rectal  examination  is  most  important,  and  the  finger  will  usually 
give  the  necessary  information.  One  can  feel  a  mass  lying  directly 
beneath  the  mucous  membrane  or  adherent  to  it.  The  surface  may 
feel  uneven  and  hard  or  there  may  be  occasionally  a  cauliflower  or 
mushroom  growth,  or  a  constriction,  through  which  the  finger  cannot 
readily  pass.  If  it  be  barely  possible  to  feel  the  growth,  it  is  similar 
in  sensation  to  the  cervix  uteri. 

Blood,  pus,  or  sanious  material  may  be  found  on  the  finger  if  the 
growth  is  ulcerating. 

Vaginal  examination  in  women  must  be  made  to  differentiate  the 
source  of  the  tumor.  The  genito-urinary  organs  in  the  male  should 
also  be  examined. 

Simple  cicatricial  stricture  is  usually  smooth  and  not  ulcerated, 


NEOPLASMS   OF   THE   INTESTINES  569 

while  a  carcinomatous  stricture  is  usually  nodular  and  frequently 
ulcerated. 

It  is  preferable  for  accurate  diagnosis  to  excise  a  portion  under 
cocain  for  microscopic  examination. 

If  the  stricture  cannot  be  reached  by  the  finger,  Kelly's  speculum 
is  of  value.     Never  insert  the  hand  into  the  rectum. 

Metastatic  growths  in  other  organs  are  quite  frequent  from  small 
growths  of  the  rectum;  thus,  with  carcinoma  of  the  liver,  a  small 
primary  carcinoma  of  the  rectum  may  be  found,  even  if  no  symptoms 
are  present. 

The  bladder  and  vagina  may  be  involved  and  fistulous  openings 
occur.     Periproctitis  (abscess)  and  fistulae  are  rare. 

The  peritoneum  is  rarely  involved  unless  the  carcinoma  is  high  up. 

Course. — The  termination  is  death  if  not  operated  on.  This 
may  occur  by  occlusion  of  the  intestines  and  from  peritonitis. 

It  is  hardly  possible  to  give  a  prognosis  as  to  duration.  In 
cancer  of  the  duodenum  the  general  nutrition  suffers  early,  or  the 
case  may  be  very  acute  and  the  duration  of  life  is  short.  In  many 
cases  the  course  varies  from  six  months  to  two  years,  while  in  rectal 
cancer  it  may  last  for  three  to  even  four  years.  Rarely  cases  come 
to  a  standstill  and  last  some  years. 

In  some  cases  coma  (carcinomatosum)  appears  quite  early, 
probably  due  to  auto-intoxication  from  intestinal  decomposition 
or  from  the  toxins  of  cancer.  Ewald  isolated  a  body  from  the  urine 
belonging  to  the  group  of  diamins  in  such  a  case. 

Thrombosis  may  develop  and  embolus  of  the  lungs  occur,  with 
death  resulting.     Death  may  occur  from  exhaustion. 

Diagnosis. — Presence  of  a  tumor  by  abdominal  palpation  or 
rectal  examination,  accompanied  by  cachexia  floss  of  weight  marked) 
and  anemia,  with  marked  constipation  and  increasing  symptoms  of 
stenosis  of  the  bowel;  or  cachexia,  intestinal  disturbances,  with  no 
detectable  tumor,  but  with  symptoms  of  progressive  stenosis  in  an 
elderly  person,  are  suggestive  of  cancer.  Examination  of  a  tumor 
fragment,  if  it  can  be  secured  in  the  stool  or  from  the  rectum,  is 
conclusive. 

Prognosis. — This  is  fatal,  unless  early  and  complete  removal. 

Treatment. — Complete  and  early  removal  of  the  growth  is 
indicated.  An  early  diagnosis  is  important.  If  abdominal  cancer 
is  suspected,  exploratory  laparotomy  and  complete  resection  with 
end-to-end  or  lateral  anastomosis  are  indicated. 

If  resection  is  impossible,  entero-enterostomy  or  enterocolostomy 
for  drainage  to  relieve  symptoms. 

If  the  tumor  is  low  down  in  the  colon,  sigmoid,  or  rectum  and 
inoperable,  then  colostomy  to  relieve  the  symptoms  and  prevent 
irritation  of  the  surface  of  the  cancer. 

In  the  rectum,  resection,  preferably  Kraske's  operation,  is  indicated 
if  radical  operation  is  possible. 


570  DISEASES   OF  THE   STOMACH  AND   INTESTINES 

Palliative  curetment  and  the  thermocautery  may  be  employed 
in  some  cases.  Colostomy  under  cocain  can  be  performed  in  the 
aged  and  feeble. 

Trypsin  treatment,  described  under  Gastric  Cancer,  is  pistifiable 
in  inoperable  cases,  or  in  those  in  which  a  palliative  operation  has 
been  performed.  Coley's  treatment  by  erysipelas  toxins  may  be 
tried,  but  I  would  not  recommend  "it.  It  is  more  successful  with 
sarcoma. 

Diet. — Soluble  foods  with  little  residue,  such  as  milk,  broth, 
bouillon,  sanatogen,  somatose,  cream,  butter,  rice-gruel,  sour  milks, 
matzoon,  kumyss,  bacillac,  etc.,  are  indicated. 

Irrigation  of  the  intestines,  enemata,  and  injections  wdth  olive 
oil,  and  internally,  castor  oil,  magnesium  sulphate,  rhubarb,  cascara, 
etc.,  to  keep  movements  soft;  warm  applications  to  the  abdomen; 
morphin,  codein,  and  belladonna  are  indicated  for  pain.  These  last 
can  be  given  by  suppository.  Strength  should  be  supported  by 
tonics,  iron,  arsenic,  etc.,  and  pain  relieved.     Treat  complications. 

SARCOMA  AND  LYMPHOSARCOMA  OF  THE  INTESTINES 

•  Sarcoma  of  the  intestines  is  rather  an  infrequent  disease,  much 
less  frequent  than  carcinoma.  In  the  course  of  twelve  5-ears,  1882-93, 
in  the  Vienna  General  Hospital,  out  of  274  autopsies  on  sarcoma, 
only  3  were  sarcoma  of  the  intestines,  the  ileum,  cecum,  and  rectum. 
In  61  cases  of  lymphosarcoma,  9  belonged  to  the  intestines,  i  in  the 
duodenum,  3  in  the  jejunum,  3  in  the  ileum,  and  2  in  the  cecum. 

Of  Tibmann's  cases,  15  were  of  the  duodenum,  18  of  the  jejunum 
and  ileum,  14  of  the  ileum,  and  3  of  the  entire  small  intestine. 

Sarcoma  occurs  as  frequently  in  the  small  as  in  the  large  intestine, 
and  lymphosarcoma  preponderates  in  the  small  bowel, 

Of  Krueger's  37  cases,  16  were  of  the  small  bowel  alone  and 
16  of  the  rectum;  the  ileocecal  region  comes  next. 

Sarcomata  usually  attain  a  large  size,  even  as  large  as  a  child's 
head,  and  spread  over  a  large  part  of  the  intestines. 

Anatomy. — -Sarcomata  usually  originate  in  the  submucosa,  the 
musculature  is  attacked  early,  and  the  serosa  is  rarely  involved. 
Small  round-celled  sarcoma  is  most  frequent;  occasionally  spindle 
celled.     In  the  rectum  they  are  often  melanotic. 

Lymphosarcomata  start  from  the  lymphatic  apparatus,  the 
solitary  and  agminate  lymph-follicles.  These'  occur  chiefly  in  the 
small  intestine. 

Sarcomata  of  the  intestines  show  a  rapid  progress  and  metastases 
are  found  early.  They  do  not  produce  stricture  of  the  bowel,  but  a 
dilatation,  and  develop  in  a  longitudinal  direction  along  the  intestines. 
The  bowel  mav  be  enormously  dilated.  Rectal  sarcoma,  however, 
may  produce  obstruction. 

Age. — Sarcoma   is   frequent   in   young   persons;   most   frequent 


NEOPLASMS   OF   THE    INTESTINES  57I 

from  twenty  to  forty  years  of  age ;  from  four  to  seventy  years  cases 
are  reported,  and  one  congenital  case  in  an  infant  three  days  old. 

Symptoms. — The  clinical  symptoms  differ  from  carcinoma. 
The  general  health  becomes  impaired  early.  The  patients  emaciate 
rapidly  and  become  anemic.  There  is  a  peculiar  want  of  proportion 
between  the  rapid  impairment  of  the  physical  condition  and  the 
absence  of  local  symptoms.  They  become  rapidly  weak  and  debili- 
tated (cachexia).  There  are,  as  a  rule,  an  absence  of  abdominal 
pain  and  no  symptoms  of  stenosis.  Intestinal  s3Tnptoms  are  slight — 
occasionally  constipation,  alternating  with  diarrhea. 

Exceptionally,  stenotic  symptoms  appear,  due  to  kinking  or 
peritonitic  incarceration,  rarely  ileus.  Stenosis  occurs  in  rectal 
carcinoma. 

The  tumor  appears  early,  grows  rapidly,  and  can  easily  be  made  out. 

Duration. — ^The  majority  of  cases  die  within  nine  months  from 
general  cachexia;  only  i  case  recorded  lived  twenty-one  months. 

Prognosis. — This  t^^pe  of  tumor  proves  fatal,  and  even  early 
operation  seems  of  no  value  on  account  of  the  metastases. 

Treatment. — Injection  of  Coley's  fluid,  the  mixed  toxins  of  ery- 
sipelas and  Bacillus  prodigiosus,  is  indicated,  as  in  inoperable  sar- 
coma in  the  other  regions.  One  must  remember  that  marked  reac- 
tion follows  the  injection  in  some  cases,  and  some  patients  cannot 
undergo  the  treatment.  I  have  seen  the  latter  occur,  and  also  in 
another  case  temporary  improvement. 

The  patient  should  receive  as  liberal  a  diet  as  possible,  and  iron, 
arsenic,  and  cod-liver  oil  should  be  administered.  As  a  rule  no 
stenosis  is  present,  but  if  in  evidence,  operative  procedure  is  indicated. 
Removal  has  failed  on  account  of  metastases. 

BENIGN  TUMORS  OF  THE  INTESTINES  (NEOPLASMS) 

Benignant  neoplasms  of  the  intestines  are  relatively  rare,  and 
their  clinical  significance  is  generally  slight.  They  occasionally 
produce  severe  symptoms. 

These  tumors  may  be  attached  to  the  bowel  wall  by  a  broad 
base  or  by  a  thin  pedicle  or  stem,  and  are  then  termed  polypi.  The 
last  type  is  usually  of  small  size,  that  of  a  cherry,  but  rarely  as  large 
as  a  pear,  and  occur  most  frequently  in  the  rectum. 

The  following  forms  of  benign  tumor  are  found :  Adenoma,  fibroma, 
lipoma,  papilloma,  myoma,  fibromyoma,  angioma,  and  chylangioma. 

Adenomata  are  most  frequently  met  with.  They  arise  from  the 
glands  of  Lieberkiihn  and  in  the  duodenum  from  Brunner's  glands; 
are  acinous  in  structure,  and  may  be  attached  to  the  bowel  by  a 
broad  base  or  by  a  pedicle.  As  a  rule  they  are  small,  the  size  of  a 
pea,  rarely  the  size  of  a  pear.  They  are  red  and  have  a  tendency  to 
bleed;  usually  they  are  soft  and  the  surface  is  smooth,  though  occa- 
sionally of  a  cauliflower  appearance.  They  occur  most  frequently 
in  the  rectum,  are  usually  polypoid,  though  occasionally  annular  and 


572  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

flat.  They  are  most  common  in  children  from  four  to  seven  years, 
though  occasionahy  in  adults.  More  than  half  the  cases  that  occur 
are  in  males  between  sixteen  and  thirty  years  of  age.  Sometimes 
there  is  extensive  involvement  of  the  intestines,  a  condition  known 
as  polyposis  intestinalis  adenomatosa;  in  i  case  several  thousand 
were  present.  Polypi  are  never  limited  to  the  small  intestine. 
Carcinomatous  degeneration  of  the  polypi  may  occur. 

Fibroma,  Lipoma,  Papilloma. — These  neoplasms  derived  from 
the  connective  tissues,  especially  from  the  submucosa,  are  very  rare. 
They  are,  as  a  rule,  lipomatous  in  structure,  and  often  originate  from 
the  appendices  epiploicae.  They  frequently  project  into  the  peri- 
toneal cavity  and  may  twist  their  pedicle  and  become  detached. 
They  may  have  a  broad  base  or  pedicle,  are  of  various  shapes,  and 
may  grow  to  the  size  of  an  apple.  The^/  occur  most  frequently  in 
>the  colon  and  rectum,  less  frequently  in  the  jejunum,  and  rarely  in 
the  ileum. 

Myoma,  Fibromyoma. — These  are  very  rare  and  usually  orig- 
inate from  the  outer  muscular  coat  of  the  intestines,  chiefly  from 
the  longitudinal  coat.  There  are  two  forms:  Spheric  nodules, 
which  grow  toward  the  mucous  lining  and  sometimes  become  pedun- 
culated, the  mucous  membrane  lying  loose  in  front;  or  they  may 
have  a  broad  thick  base,  forming  a  circumscribed  thickening,  the 
mucous  membrane  being  adherent. 

Rarely  the  myoma  will  grow  toward  the  peritoneal  cavity. 

Angiomata. — These  are  exceedingly  rare,  and  may  occur  as  a 
telangiectatic  mass,  or  as  a  flat  vascular  tumor  involving  more  or  less 
of  the  bowel  wall.     Cystic  chylangiomata  occur  in  the  small  intestine. 

Sjrmptoms. — In  many  cases  there  are  no  S3Tiiptoms  at  all,  and 
the  condition  is  discovered  accidentally  post  mortem. 

Sometimes  they  give  rise  to  intestinal  hemorrhage.  When  this 
occurs  in  a  person  in  good  health,  who  has  never  given  any  history 
of  previous  intestinal  trouble,  the  possibihty  of  an  intestinal  tumor 
should  be  thought  of.     This  is  especially  true  in  children. 

Diarrhea  with  blood  and  mucus  have  been  reported  in  cases  of 
polyposis  intestinalis  adenomatosa.  On  account  of  their  small  size 
it  is  nearly  impossible  to  discover  them  by  palpation. 

Symptoms  may  rarely  be  produced  by  narrowing  or  occlusion  of 
the  bowel  by  the  intestinal  tumor,  or  from  an  intussusception  caused 
by  the  tumor.  When  tumors  are  situated  in  the  rectum  disturb- 
ances are  most  likely  to  occur,  such  as  hemorrhage,  passage  of 
mucus,  tenesmus,  and  difflcult  defecation. 

Sometimes  the  mass  may  be  felt  by  the  examining  finger,  and 
it  may  even  protrude  from  the  anus  and   give  rise  to  severe  pain. 
It  may  occasionally  be  torn  off  and  passed  with  the   stools,  when 
the  symptoms  may  disappear. 

Course. — They  may  remain  latent  or  give  symptoms  for  some 
years  and  then  be  passed  per  rectum. 


NEOPLASMS    OF    THE    INTESTINES  573 

Treatment. — Intestinal  hemorrhage  should  be  treated  in  the 
manner  already  described  under  Typhoid.  The  blood  will  often  be 
bright  in  color  if  the  hemorrhage  is  from  the  colon  or  rectum ;  injec- 
tion of  very  hot  or  cold  water  with  5j  (4.0)  of  alum  or  tannic  acid, 
gr.  30  (2.0),  locally,  or  Tremoliere's  solution,  by  mouth  and  rectum; 
ice-bag  to  the  abdomen;  morphin,  gr.  I  (0.016),  and  ernutin,  lUv 
(0.296),  by  hypodermic,  are  indicated. 

If  the  tumors  are  accessible  in  the  rectum,  they  should  be  removed 
by  galvanocautery  or  by  operation. 

GAS  CYSTS  OF  THE  INTESTINES 

(Synonym. — Pneumatosis  Cystoides  Intestinorum  Hominis.) 

Cysts  containing  air,  in  the  intestines  of  pigs,  were  probabh'  first 
described  by  Mayer,^  of  Bonn.  This  condition  was  also  indepen- 
dently described  by  John  Hunter.  These  intestinal  gas  cysts  have 
been  found  quite  frequently  in  apparently  otherwise  healthy  pigs 
and  occasionally  in  sheep.  The  theory  has  been  held  that  bacteria 
are  the  cause,  or  that  they  are  the  result  of  mechanical  and  physical 
conditions ;  for  example,  that  gas  may  escape  through  some  abrasion 
into  the  tissues.  Bang^  first  reported  this  condition  in  the  human 
being,  and  Finney  the  first  case  in  America. 

Finney  and  Welch^  believe  the  cyst  to  be  a  distinct  variety  of 
tumor,  the  cells  of  which  have  the  faculty  of  secreting  gas.  In  prac- 
tically every  case  so  far  the  gaseous  cyst  has  been  associated  with 
disease  of  some  portion  of  the  intestinal  canal,  producing  an  obstruc- 
tion to  the  lumen  of  the  bowel.  Cysts  may  be  single  or  multiple 
and  in  the  small  and  large  intestines. 

Pathology. — There  is  a  dense  fibrous  tissue  framework  contain- 
ing round  and  spindle  cells,  and  there  are  clefts  arid  spaces  whose 
walls  contain  large  giant  cells  with  many  nuclei.  Air  spaces  are 
found  about  these  cells,  and  there  is  an  endothelial  lining  to  these 
spaces.  The  blood-supply  is  rich  and  hemorrhages  may  occur  in  the 
tissues.  Air  in  the  cyst  resembles  atmospheric  air.  The  tumor  is 
'more  pronounced  in  the  subserous  tissue,  though  it  has  been 
observed   in  all  the  layers  of  the  walls. 

Clinically,  there  is  no  definite  picture.  Crepitation  on  palpation 
has  been  noted.  Pain  and  constipation  could  be  chieliy  attributed 
to  other  factors. 

Diagnosis  is  usually  made  during  operation  for  some  other 
trouble  or  at  autopsy. 

Treatment. — If  symptoms  of  obstruction,  operation  is  indicated. 
After  operation  for  other  conditions,  they  generally  diminish  in  size 
or  disappear. 

1  Jour.  d.  prakt.  Heilk.,  1825. 

2  Nord.  med.  Ark.,  1876,  viii,  No.  18. 

3  Jour.  Am.  Med.  Assoc,  October  17*  1908. 


CHAPTER  XXVIII 
HEMORRHOIDS;  PROLAPSE  OF  RECTUM;  FISSURE 

HEMORRHOIDS 

(Synonyms. — Phlebectasia  Hemorrhoidalis;  Piles.) 

Hemorrhoids  consist  of  diffuse  or  circumscribed  varicose  dilata- 
tions of  the  hemorrhoidal  veins,  lying  either  in  the  subcutaneous 
tissue  of  the  anus  external  to  the  sphincter  (external  hemorrhoids) 
or  in  the  submucous  tissue  of  the  lower  portion  of  the  rectum  (inter- 
nal hemorrhoids). 

The  hemorrhoidal' veins  surround  the  lower  portion  of  the  rectum 
and  there  form  the  hemorrhoidal  plexus.  The  majority  of  these  veins 
enter  into  the  inferior  or  external  inferior  hemorrhoidal  veins,  and 
from  there  into  the  common  pudic  and  iliac  veins;  others  pass  into 
the  median  inferior  hemorrhoidal  veins  and  so  into  the  internal  iliac 
vein  and  the  inferior  vena  cava.  A  small  number  of  the  veins  enter 
the  superior  hemorrhoidal  veins,  thence  into  the  inferior  mesenteric 
veins  and  the  portal  system. 

In  portal  obstruction  blood  from  the  hemorrhoidal  plexus  can 
pass  into  the  vena  cava;  while  back  pressure  on  the  vena  cava 
inferior,  as  of  cardiac  origin,  may  affect  the  hemorrhoidal  system. 
All  hemorrhoidal  veins  are  devoid  of  valves. 

Anatomy. — External  hemorrhoids  are  visible  to  the  naked  eye, 
lie  below  the  sphincter  ani,  and  are  often  arranged  in  groups  around 
the  anal  orifice.  They  appear  as  bluish- red,  tortuous  vessels  encircling 
the  opening;  or  there  may  be  isolated  varicose  protrusions,  from  the 
size  of  a  pea  to  a  walnut.  They  may  be  round,  flat,  or  irregular  in 
shape  and  their  size  sometimes  changes  in  the  same  patient,  often 
being  smaller  after  defecation. 

Internal  hemorrhoids  often  can  only  be  discovered  by  digital 
examination  or  by  use  of  the  proctoscope,  as  they  lie  above  the 
sphincter.  In  aggravated  cases  the  patient  by  bearing  down  may 
cause  them  to  protrude.  They  usually  appear  as  soft  nodules  of 
bluish  hue,  with  thin  walls. 

The  diffuse  or  circumscribed  nodular  forms  may  be  present,  and 
the  last  constitute  a  true  varix. 

External  and  internal  hemorrhoids  may  occur  together.  Piles 
may  occur  singly  or  in  pairs,  or  be  multiple  and  form  a  ring  about  the 
anal  opening,  both  external  and  internal  to  the  sphincter,  and  even 
a  third  higher  ring  has  been  described.  In  exceptional  cases  dilated 
veins  are  found  high  up  the  rectum  even  into  the  sigmoid  flexure. 
574 


hemorrhoids;  prolapse  of  rectum;  fissure  575 

Hemorrhoids  are  generally  believed  to  be  simple  venous  ectasias 
and  are  considered  genuine  varices,  though  some  maintain  them  to 
be  true  angiomata.  * 

Secondary  changes  probably  account  for  the  various  conditions 
found.  The  dilated  blood-vessels,  venous  varices,  near  a  group  of 
hemorrhoids  may  become  inflamed,  adhere  and  coalesce,  and  the 
walls  of  the  vessels  atrophy,  so  that  tumors  of  some  size,  resembling 
cavernous  multilocular  tumors  (angiomata),  may  develop. 

The  external  covering  of  the  varix  may  become  hard,  thick,  and 
resistant,  through  inflammatory  processes.  In  other  cases  the  walls 
may  become  thin  and  eventually  rupture,  or  the  blood  coagulate 
within  the  pile  and  form  a  thrombus. 

Phleboliths  occur  in  old  cases.  A  blood-cyst  is  occasionally 
formed. 

Marked  connective-tissue  increase  may  take  place  in  some  of 
the  external  hemorrhoids;  they  may  present  the  appearance  of  skin 
tabs,  or  skin  externally  and  mucous  membrane  internally,  which 
may  become  edematous  and  inflamed.  They  may  give  rise  to  warty 
growths. 

The  mucous  membrane  of  the  rectum  near  the  hemorrhoids  is 
hyperemic,  and,  with  internal  hemorrhoids,  in  a  condition  of  catarrhal 
inflammation. 

Fissure  or  prolapse  of  the  rectum  may  be  associated  with  piles. 

Allingham  has  subdivided  internal  hemorrhoids  into  three 
varieties : 

1.  Capillary  piles,  resembling  nevi,  consisting  of  hypertrophic 
capillary  vessels  and  spongy  connective  tissue  with  thin  mucous 
"membrane.     They  easily  bleed. 

2.  Arterial  piles,  sessile  or  pedunculated  tumors,  ghstening  or 
villous,  slippery,  hard,  and  vascular. 

3.  Venous  piles,  in  which  the  veins  predominate.  Tumors  are 
large  and  bluish  or  livid  in  color. 

Internal  piles  may  be  pushed  down  during  defecation.  A 
pedicle  may  be  formed  to  the  tumor  and  the  mass  ma}'^  slip  out  of 
the  rectum.  After  defecation  they  may  spontaneously  return 
into  the  bowel,  or  can  be  replaced.  If  large  they  may  become  incar- 
cerated and  even  gangrenous  and  slough  off.  Hemorrhage  is  a 
common  occurrence. 

Inflammatory  processes  may  complicate  internal  piles,  such  as 
ulcers,  proctitis,  and  periproctitis.  With  the  latter  abscess  may 
result,  which  may  form  fistula?,  external,  internal,  or  complete. 

Etiology. — Hemorrhoids  are  frequently  met  with  in  practice 
and  the  condition  is  much  more  common  than  supposed,  as  many 
patients  so  afflicted  never  consult  the  physician.  It  is  rare  in 
children. 

The  statement  is  often  made  that  piles  occur  more  frequently  in 
men  than  in  women.     Undoubtedly  more  male  cases  are  found  in  our 


576  DISEASES   OP   THE    STOMACH   AND   INTESTINES 

records.  Habitual  constipation,  pelvic  congestion,  and  sedentary 
life  favor  markedly  the  production  of  hemorrhoids,  and  these  con- 
ditions we  find  most  frequent  in  women.  Males  will  at  once  consult 
the  physician  if  there  is  difficulty  in  the  anal  region.  Women  are, 
as  a  rule,  extremely  sensitive  and  usually  treat  their  piles  by  home 
remedies  until  conditions  are  such  as  to  necessitate  advice  from  the 
physician.  It  has  been  my  experience  that  most  of  my  women 
patients  never  refer  to  ' '  hemorrhoids ' '  unless  specifically  questioned. 
Actually  I  believe  women  are  the  more  frequently  afflicted. 

Age. — Piles  occur  most  frequently  between  thirty  and  fifty  years 
of  age.  The  modern  consensus  of  opinion  is  that  hemorrhoids  are 
a  local  disease  and  not  due  to  any  diathesis  or  faulty  state  of  the 
general  circulation.  There  are  certain  peculiarities  in  the  rectal 
plexus  of  veins  favoring  the  production  of  piles  which  are  as  follows : 

The  walls  of  the  hemorrhoidal  veins  are  thin  and  contain  few 
muscular  fibers,  and  hence  their  contractile  force  is  less  than  that  of 
the  veins  in  the  lower  limbs. 

There  are  no  valves  in  the  rectal  veins,  so  that  blood  can  be 
readily  forced  back  into  them.  Muscular  contraction  aids  the 
onward  propulsion  of  the  blood  in  other  regions. 

In  the  rectum  fecal  masses  compress  the  blood-vessels,  the  sphinc- 
teric  contractions  compress  the  vessels,  and  contraction  of  the  ab- 
dominal muscles  during  defecation  interfere  with  the  return  of  blood. 
Thev  are  dependent  blood-vessels,  and  with  the  unfavorable  factors 
mentioned  it  is  not  surprising  that  hemorrhoids  are  frequent. 

Some  of  the  hemorrhoidal  veins  enter  the  portal  system,  in  which 
there  is  a  low  degree  of  pressure  and  in  which  the  circulation  is 
readily  retarded.  Stasis  of  this  system  may  be  a  contributory  factor 
in  the  production  of  hemorrhoids,  as  in  cirrhosis  of  the  liver;  as  may 
also  diseases  of  the  heart  and  lungs  leading  to  engorgement  of  the 
venous  system. 

All  conditions  which  tend  to  produce  interference  with  the  return 
circulation  of  blood  from  the  hemorrhoidal  vessels,  or  produce  or 
predispose  to  hyperemia,  influence  the  production  of  hemorrhoids. 
Among  such  are:  chronic  constipation;  sedentary  habits,  as  in 
clerks,  students,  shoemakers,  seamstresses,  sitting  on  soft  cushions, 
excessive  horseback  riding,  etc. ;  enlarged  uterus,  as  from  disease  or 
pregnancy;  prostatic  affections,  tumors  of  the  bladder  or  growths  in 
the  pelvis. 

Hemorrhoids  may  develop  suddenly  in  cases  of  carcinomatous 
stricture  of  the  rectum  and  early  in  the  course  of  the  disease. 

Habitual  constipation  favors  the  production  of  piles.  Hemor- 
rhoids also  may  be  the  primary  condition,  and  on  account  of  the  pain 
of  defecation  the  patient  avoids  having  a  movement  as  long  as  possi- 
ble. Excessive  venery  is  given  as  causing  congestion  in  these  regions. 
Abuse  of  alcohol,  spiced  food,  fatty  food,  excessive  quantities  of  food 
and  drink  are  believed  by  some  to  favor  the  plethoric  habit  and 


hemorrhoids;  prolapse;  of  rectum;  fissure  577 

produce  fulness  of  the  portal  circulation,  with  resulting  piles.  Gour- 
mands of  this  type  are  often  of  sedentary  habit  and  are  frequently 
disposed  to  constipation — a  more  likely  cause.  Von  Recklinghausen 
has  shown  that  piles  are  by  no  means  common  in  plethoric  individuals, 
but  more  in  those  of  lean  habit,  of  poor  muscular  development,  with 
defective  metabolism,  who  lead  a  sedentary  life,  and  who  are  anemic, 
with  poor  circulation.  Catarrh  of  the  rectum  is  given  as  a  cause, 
but  it  is  not  always  easy  to  determine  whether  the  catarrh  or  piles 
were  primary.  Drastic  purgatives  are  said  to  produce  hemorrhoids, 
but  they  are  used  for  the  constipation,  which  may  be  the  chief  factor, 
Cases  do  occur  in  which  it  seems  probable  that  the  excessive  use  of 
purges  has  produced  hemorrhoids  with  prolapse. 

Among  the  Orientals,  who  lead  a  sedentary  life,  hemorrhoids 
seem  quite  common.  Hereditary  anatomic  peculiarities  have  been 
suggested  as  a  cause,  since  piles  are  often  found  in  several  successive 
generations. 

Symptoms. — External  Hemorrhoids. — ^These  are  chiefly  of  local 
character.  The  patient  may  have  a  sensation  of  fulness,  clogging, 
or  pulsation  in  the  lower  rectum.  At  times  there  may  be  a  feeling  of 
obstruction  at  the  time  of  bowel  movement.  Constipation  usually 
precedes  the  attack. 

There  is  itching  of  the  anus  and  perineum.  The  anus  may  be 
tender  and  swollen,  and  if  the  buttocks  are  drawn  apart  external 
piles,  single  or  in  clumps,  round  and  bluish  in  color,  distended  with 
blood,  are  present.  Stains  of  blood  are  often  found  on  the  toilet 
paper.  The  exacerbation  may  quiet  down  under  rational  methods. 
They  may  become  swollen  and  edematous,  painful,  and  even  ulcerate 
and  suppurate,  with  the  production  of  a  fistula. 

Tenesmus  may  be  present,  and  the  external  pile  may  be  drawn 
up  into  the  sphincteric  circumference  and  become  pinched  and  stran- 
gulated. Under  such  conditions  there  are  severe  pain,  throbbing, 
a  desire  for  defecation  with  straining,  and  the  patient  cannot  sit  or 
walk  about.  Fever,  anorexia,  and  severe  constipation  accompany 
the  local  manifestations. 

Hemorrhage  is  not  as  marked  with  external  piles. 

Internal  Hemorrhoids. — With  internal  hemorrhoids  hemorrhage  is 
often  a  prominent  symptom.  Frequently  internal  piles  can  only 
be  detected  by  digital  examination  or  by  inspection  through  a 
speculum.  They  may  prolapse  and  even  become  strangulated. 
In  such  event  the  pile  becomes  swollen,  turns  deep  blue,  there  is 
agonizing  pain,  marked  tenesmus,  occasionally  vomiting,  constipa- 
tion, meteorism,  fainting,  prostration,  and  fever. 

Gangrene  and  sepsis  may  occur  if  the  strangulation  is  not  relieved. 

With  mild  types  of  internal  hemorrhoids  the  only  symptom  may 
be  an  occasional  hemorrhage.  One  must  remember  that  hemor- 
rhoidal veins  may  be  very  high  up  and  only  be  visible  with  a  procto- 
scope. 

37 


578  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

Usually,  subjective  symptoms  are  present,  such  as  itching,  burn- 
ing, pressure  and  weight  in  the  anus,  and  the  sensation  of  a  foreign 
body,  with  tenesmus.  There  may  be  feelings  of  pressure  and  even 
pain  in  the  sacral  and  lumbar  regions.  Occasionally  soreness  over 
the  lower  part  of  the  abdomen,  pressure  in  the  rectum,  bladder, 
uterus,  and  vagina;  pains  radiating  to  the  thighs  may  be  present. 
Sometimes  these  symptoms  precede  a  hemorrhage,  after  which 
temporary  relief  occurs. 

As  a  rule,  the  bowels  are  irregular  and  constipated. 

Hemorrhages  may  be  frequent,  so  as  to  cause  marked  secondary 
anemia.  Bleeding  may  be  severe  and  bright  red  blood  gush  from  the 
rectum  nearly  pure,  or  it  may  be  dark  brown  mixed  with  fecal  mat- 
ter. In  such  an  event  it  lies  on  the  surface  of  the  feces  and  is  not 
intimately  mixed  with  it.  Small  quantities  of  blood  are  frequently 
passed  with  hard  stools. 

Hemorrhages  sometimes  occur  on  no  special  provocation,  or 
after  a  horseback  or  bicycle  ride,  etc. 

Gummy  acrid  mucus  may  be  discharged  from  the  hemorrhoids 
due  to  catarrh  of  the  rectum,  and  may  cause  excoriations. 

In  some  the  hemorrhage  may  last  for  several  days  and  temporary 
relief  may  occur.  It  has  been  stated  that  bleeding  from  hemorrhoids 
may  take  the  place  of  menstruation  (vicarious). 

Dyspnea,  palpitation,  angina,  hiccough,  giddiness,  despondency, 
and  hypochondria,  often  attributed  to  piles,  I  believe,  with  Riegel, 
are  merely  associated  with  the  constipation  present. 

Proctitis,  fissure,  and  occasionally  abscesses  or  fistulae  may 
develop. 

Disturbances  of  adjacent  organs,  such  as  strangury,  hemorrhage 
from  the  bladder  or  vagina,  or  catarrh  of  the  latter  may  occasionally 
occur. 

Diagnosis  is  made  by  inspection  and  digital  examination;  occa- 
sionally the  proctoscope  is  necessary.  The  appearance  of  hemor- 
rhoids has  been  described. 

Condylomata  encircle  the  anus  and  are  often  present  on  the 
scrotum.     There  are  a  history  of  syphilis  and  manifestations  of  lues. 

Skin  tags  are  whitish  looking,  do  not  change  their  size,  and  do 
not  bleed  when  punctured.     Piles  differ  in  the  last  regard. 

Internal  hemorrhoids  are  reddish  blue  and  bleed  when  punctured ; 
polypi  do  not  do  so.     The  latter  occur  most  frequently  in  children. 

Carcinoma  presents  a  hard  consistency,  stenotic  s\TTiptoms,  and 
cachexia.  A  small  section  placed  under  the  microscope  will  settle 
the  diagnosis. 

Piles  may  occur  suddenly  in  association  with  cancer. 

Prognosis. — Piles  are  frequently  a  chronic  affection  and  may 
exist  throughout  Ufe.  In  cases  occurring  during  pregnancy,  restitu- 
tion to  normal  is  possible.  This  is  true  of  the  milder  types  if  the 
cause  is  corrected.     They  may  markedly  diminish  in  size  and  then 


hemorrhoids;  prolapse  of  rectum;  fissure  579 

an  exacerbation  take  place.  They  rarely  endanger  life  unless  stran- 
gulation with  gangrene  or  a  large  abscess  or  dangerous  hemorrhage 
occur. 

Treatment. — Excesses  of  all  kinds  in  food,  drink,  and  venery 
should  be  avoided.  The  patient  should  lead  an  out-of-door  life, 
take  proper  exercise,  and  have  a  daily  soft  evacuation  of  the  bowels. 

All  conditions  causing  venous  engorgement  of  the  rectum  should 
be  avoided,  such  as  constant  standing  or  sitting,  horseback  and 
bicycle  riding.  The  patient  should  not  sit  on  warm  soft  cushions, 
but  on  cane-seats  or  those  covered  with  leather  or  horse-hair. 

'  Diet. — The  diet  should  be  mixed  in  character  and  in  part  consist 
of  a  considerable  variety  of  green  vegetables  and  raw  ripe  and 
cooked  fruits,  to  regulate  the  bowels. 

It  should  suit  the  individual,  and  a  stout  full-blooded  person 
must  be  somewhat  limited  in  his  diet.  The  patient  should  not  take 
three  large  meals  at  long  inter\^als,  but  preferably  smaller  and  more 
frequent  feedings. 

Alcoholic  beverages,  strong  coffee,  strong  tea,  highly  seasoned 
dishes,  cheese,  coarse  brown  bread,  peas,  corn,  and  baked  or  lima 
beans  are  best  avoided. 

String  beans,  spinach,  asparagus,  and  green  salads  aid  bowel 
action.  Potatoes,  rice,  beets,  and  cauliflower  may  be  allowed  in 
small  quantity.  Raw  fruits,  such  as  apples,  pears,  prunes,  grapes, 
oranges,  and  stewed  fruits,  such  as  prunes,  baked  apples,  etc.,  are 
of  value.  vSoups  of  various  kinds  are  allow^ed.  Hot  breads,  richly 
spiced  foods,  and  rich  desserts  should  be  avoided. 

Matzoon,  kumyss,  bacillac,  lactone-milk,  and  buttermilk  often 
have  an  excellent  effect  on  the  bowels.  They  can  be  taken  as  the 
extra  meals  midway  between  the  usual  m.eals.  A  few  crackers  or 
zwieback  with  plenty  of  butter  can  be  given.  Some  recommend 
water  only  between  meals  and  interdict  much  of  that.  Unquestion- 
ably a  certain  amount  of  fluid  with  the  food  is  an  aid  to  digestion  and 
bowel  action.  I  have  seen  severe  cases  of  constipation  result  from 
the  elimination  of  all  fluids  at  meals. 

At  least  oviij  (250  cc.)  of  fluid  in  the  form  of  broth,  soup,  cocoa, 
or  water  should  be  taken  at  each  meal.  On  rising,  administration 
of  a  glass  of  water  often  aids  bowel  action,  and  between  meals  an 
equal  amount  should  be  given,  or  matzoon  or  kumyss  substituted. 

Outdoor  exercise,  such  as  walking,  is  of  service.  It  should  not 
be  carried  to  the  point  of  fatigue  and  is  contra-indicated  during 
acute  inflammation  of  the  piles  or  if  hemorrhage  or  unpleasant 
svmptoms  result.  Massage,  gymnastics,  and  Swedish  movements 
are  of  value. 

Bowels. — Constipation  should  receive  appropriate  treatment. 
Powerful  cathartics  should  be  avoided.  The  dietary  methods  men- 
tioned should  be  carried  out.  The  patient  should  go  to  stool  daily 
at  a  definite  hour.     I  have  found  the  administration  of  olive  oil, 


580  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

I  to  2  tablespoonfuls  (15.0-30.0)  t.  i.  d.  before  meals,  an  aid  to  bowel 
action.  The  injection  of  oj  to  ij  (30.0-60.0)  of  olive  oil  into  the 
rectum  with  a  small  soft-rubber  ear  syringe  just  before  having  or 
attempting  to  have  a  movement  is  a  valuable  procedure.  It  renders 
the  passage  easier  and  less  painful. 

Aloes  should  be  avoided  in  hemorrhoid  cases. 

Among  our  simple  remedies  are  compound  liquorice  powder, 
oj  (4-0);  fiuidextract  of  cascara  or  aromatic  fluidextract,  oj  (4-0); 
extract  of  cascara,  gr.  i  to  5  (0.06-0.3);  purgin  (phenolphthalein) , 
gr.  1 2^  to  5  (0.1-0.3) ;  tincture  of  rhubarb,  3j  (4-0),  or  extract  of  rhei, 
gr.  4  (0.25).  Other  remedies  are  described  in  the  chapter  on  Consti- 
pation. 

Carlsbad,  Kissengen,  and  Saratoga  waters  are  of  service,  especially 
at  the  springs. 

A  good  prescription  is  the  following: 

I^.     Ext.  cascara gr.  xv  (i.o) 

Ext.  belladonnse      1  .......,, 

tX   ^  .  .       y aa  Ejr.  Ill  (0.2). — M. 

Ext.  nucis  vomicae  J  a       j  \      / 

Make  12  pills. 

Sig. — One  to  two  at  bedtime. 

Hygiene  oj  the  Anus. — After  defecation,  cleansing  with  a  moist 
sponge  or  wet  cotton  is  less  irritating  than  paper. 

External  piles  should  be  protected  with  a  small  piece  of  cotton 
moistened  with  sweet  oil  or  covered  on  the  anal  side  with  vaselin. 


iifiifii'iriririiniriiiiimi 


Fig.  213. — Kemp's  tube  (cooler)  for  hemorrhoids  or  prostate. 
Fig.  214. — Kemp's  ice  tube  for  hemorrhoids. 

boric  acid,  or  zinc  ointment.  Cold  sitz-baths  and  cold  ablutions  to 
the  rectum  are  valuable.  An  external  douche  with  cold  water  is 
excellent,  thus:  A  fountain  syringe  is  filled  with  cold  water  at  about 
60°  F.  and  several  ounces  of  witch-hazel  added,  or  a  hot  douche  at 
1 10°  to  115°  F.  can  be  substituted.  The  rectal  tip  is  placed  close  to  the 
anus,  which  is  then  thoroughh*  douched.  This  is  especially  applicable 
for  external  piles,  and  lessens  congestion  even  when  they  are  internal. 

For  external  inflamed  piles  stronger  medicated  local  applications 
can  be  employed  than  with  internal  piles,  where  greater  absorption 
occurs. 

External  Hemorrhoids. — With  inflamed  piles  absolute  rest  in  bed 


hemorrhoids;  prolapse  of  rectum;  fissure  581 

or  on  a  couch  should  be  enjoined.  A  small  ice-bag  or  gauze  wrung 
out  in  cold  solution  of  witch-hazel  and  water,  equal  parts,  or  of 
lead-and-opium  wash,  are  excellent  applications.  Some  prefer  the 
application  of  warmth;  cold  is  usually  more  efficacious. 

For  the  apphcation  of  cold  to  relieve  congestion,  both  to  external 
and  internal  hemorrhoids,  the  simple  instruments  in  Figs.  213  and 
214  are  of  value. 

The  ice  tubes  for  hemorrhoids  are  made  in  a  nest  containing  several 
sizes,  in  appearance  like  a  very  small  test-tube  with  a  broad  flange, 
to  prevent  slipping  into  the  bowel.  The  tube  is  filled  with  powdered 
ice,  corked,  well  lubricated,  and  inserted  into  the  anus.  They  are 
of  glass  or  metal,  the  latter  the  safer. 

The  prostatic  cooler  is  of  small  caliber— a  simple  closed  tube  with 
a  large  entering  and  small  return  attachment.  The  fountain  syringe 
is  attached  to  the  large  branch  and  a  soft  outflow  tube  to  the  smaller. 
Very  cold   (preferably)  or  hot  water  can  be  employed.     The  soft- 


Fig-  215. — Kemp's  soft-rubber  rectal  bag,  used  as  a  cooler  for  hemorrhoids. 

rubber  rectal  bag  (Fig.  215)  is  made  on  similar  principles,  but  is 
more  bulky.^     They  were  reported  some  years  ago." 

In  addition,  one  can  attach  a  small  catheter  to  the  tip  of  the 
fountain  syringe  and,  inserting  the  soft  tube  about  i^  inches, 
thus  douche  the  internal  hemorrhoids.  The  current  should  be 
slow,  the  patient  evacuating  the  fluid  around  the  catheter  every 
minute  or  so.  Hot  or  cold  normal  saline  solution  with  witch-hazel, 
5  I  (30.0)  to  the  pint  (500  cc),  can  be  employed.  The  old  Boden- 
,hamer  recurrent  tip  or  the  flexible  or  hard-rubber  recurrent  tubes 
(Kemp)  can  be  used,  introducing  them  only  about  2  inches;  but 
with  inflamed  piles  they  are  apt  to  cause  more  pain  than  the  small 
soft  catheter. 

I  have  found  the  following  prescriptions,  recommended  bv  Samuel 
Gant,  of  value  for  the  relief  of  pain  and  inflammation  in  external 
hemorrhoids: 


I^.     Liq.  plumbi  subacet 5iv  13 

Tinct.  opii 5iiss  10 

Ac],  dcstil q.  s.  .'iv  125 

Sig. — Apply  cold,  on  gauze. 


-M. 


1  A  small  rubber  condom,  with  two  catheters  tied  in,  one  for  the  entering  and 
the  other  for  the  outflow  current,  can  be  substituted  for  this  bag. 

2  Manual  on  Enteroclysis,  Hypodermoclysis,  and  Infusion,  1900. 


582 


DISEASES    OF    THE    STOMACH   AND    INTESTINES 


or 


I^.     Ung.  stramonii 3iss 

Ung.  belladonnEe Siiss 

Ung.  acidi  tannici oss 

I^.     Morph.  sulph g^-  "J. 

Cocainae  hydrochlor §^.-. -^^j 

Vaselin oij 

I^.     Cocainse  hydrochlor gr-  v 

Ext.  bellad.        ]  > 

Ext.  opii  I  --  --•• 

Ext.  aconite       {    * ^^^'^ 

Ext.  stramonii  J 

Glycerin 5  ss 

Sig. — Apply  on  cotton,  externally. 


15 


60 


-M. 


195 
78 
.— M. 


325 


-M. 


This  last  prescription  I  prefer  to  use  first  at  about  one-third  or  one- 
half  strength.  It  should  be  employed  only  for  the  temporary  relief 
of  severe  pain  and  should  be  left  on  only  for  a  short  period,  about 
fifteen  minutes. 

Cold  or,  at  times,  hot  injections,  and  opium  and  belladonna  sup- 
positories are  excellent  for  tenesmus. 

For  internal  hemorrhoids,  when  prolapsed,  inflamed,  and  diffi- 
cult of  reduction,  it  is  advisable  to  apply  cold,  such  as  ice-water  to 
which  witch-hazel  has  been  added,  ice,  or  lead-and-opium  lotion 
(cold) ,  for  a  brief  period  to  lessen  edema  and  inflammation. 

Local  application  of  adrenalin  (i :  1000)  to  an  irreducible  pile 
lessens  congestion  and  aids  reduction. 

One  of  the  following  ointments  is  excellent  as  a  sedative: 


I^.     Morph.  sulph gr.  viij 

Hydrarg.  chlor.  mit gr-  xij 

Vaselin o  j       •       3° 

I^.     Ext.  opii .5ss  2 

Cocainae   hydrochlor gr.  x 

Mentholi ^:'^^^  ^ 

Ung.  zinci  oxidi o  j  30 


52 
78 

.— M. 
(Gant.) 


-M. 


The  prolapsed  hemorrhoid  should  be  well  lubricated  before  the 
physician  endeavors  to  push  it  up  with  the  finger.  Occasionally  an 
anesthetic  may  have  to  be  administered.  There  are  the  dangers  of 
strangulation  with  gangrene  and  sepsis  from  an  unreduced  hemor- 
rhoid. 

For  ulcerated  hemorrhoids  the  following  are  useful : 


I^.     Bismuth,  subnit oij  8 

Hydrarg.  chlor.  mit .Bij  2 

IVlorph.  sulph gr.  iij 

Glycerin 5  ij  8 

Vaselin 5  j  3" 

Sig. — Apply  with  pile  syringe  (Allingham). 

I^.     Cocainae  mur gr-  xij 

Todoformi 5j  4 

Ext.  opii 5  ss  2 

Vaselin 5  j  30 

Sig. — Apply  with  pile  syringe  (Mathews). 


6 

195 


-M. 


-M. 


hemorrhoids;  prolapse  of  rectum;  fissure  583 

For  hemorrhage  the  following  are  of  service ;  Rectal  injections  of 
ice- water,  oviij  (250  cc),  alone  or  with  tannic  acid,  gr.  5  (0.3),  dis- 
solved therein,  or  alum,  5j  (4.0),  or  witch-hazel,  equal  parts;  local 
application  of  ice-bags  or  the  ice  tube. 

Several  ounces  of  Tremoliere's  solution — gelatin  (5  per  cent.) 
with  chlorid  of  calcium  (2  per  cent.) — can  be  injected  into  the 
rectum.     It  was  originally  used  as  a  local  styptic. 

If  the  bleeding  is  from  external  piles,  styptics  can  be  applied  in 
ointment  form ;  if  from  internal  hemorrhoids,  the  ointment  can  be  in- 
serted with  the  finger  or  applicator,  or  as  a  suppository. 

Among  such  useful  remedies  are  unguentum  acidi  tannici  and 
unguentum  gallse : 

I^.     Unguentum  acidi  tannici oiv  16 

Unguentum  stramon.      \  -  -  ^  ■  :  _y^ 

Unguentum  belladonnse  j •'  "^  j" 

Ft.  ung. 

T^.     Suprarenal  ext gr.  v  [3 

01.  theob gr.  xxx       2]. — M. 

Ft.  suppos.  No.  i. 

I^.     Adrenalin  chlorid  (i:  1000) • TTLx  (.592) 

01.  theob q.  s.— M. 

One  suppository. 

Py.     Ichthyol,         I        -  ^  ^,  I 

Acidi  tannici  j                                                          o  o 

Ext.  belladonnse ) -  -  ^  1^^^ 

Ext.  stramon.      J  o  j 

Ext.  hamamelis gr.  x  6 

01.  theob q.  s.  L— M. 

Ft.  one  suppository.  (J.  P.  Tuttle.) 

An  ointment  or  suppository  containing  chrysarobin  has  been  ad- 
vised for  the  treatment  of  hemorrhage  from  piles : 

P^     Chrysarobin gr.  xv  i 

Ext.  belladonnse gr.  v  3 

Iodoform gr.  x  6 

Petrolati 5ss  15  . — M. 

Ft.  unguentum. 

I^.     Chrysarobin gr.  ij  13 

Acidi  tannici gr.  iij  I94 

Iodoform! gr.  ij  13 

01.  theob gr.  xxx  2|.— M. 

Ft.  one  suppository. 

In  many  cases  of  hemorrhage  the  simpler  remedies  are  sufficient. 
Rarely  it  may  be  necessary  to  tampon  the  rectum.  This  can  be  per- 
formed by  slipping  in  a  piece  of  cheesecloth  like  the  finger  of  a  glove, 
in  effect,  a  bag,  with  the  outside  well  lubricated.  This  is  packed  with 
cotton  tampons  or  strips  of  gauze,  and  the  distended  bag  drawn 
down  against  the  sphincter.  It  can  be  done  in  emergenc>-  without 
an  anesthetic.  If  these  measures  fail,  it  may  be  necessary  to  ligate 
the  bleeding  artery  or,  if  this  be  ipipossible,  then  the  entire  hemor- 
rhoid. 


584 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


Radical  Treatment. — Dilatation  of  the  Sphincters. — By  means  of 
this  the  spasm  of  the  sphincter  is  stopped,  the  pressure  on  the  blood- 
vessels is  relieved,  and  the  bowels  act  more  easily.  It  will  frequently 
be  of  benefit  in  the  early  stages  of  hemorrhoids,  and  I  have  seen  it 
relieve  severe  symptoms  in  advanced  cases,  especially  if  fissure  is 
associated.  The  author  has  noted  cases  in  which  several  years 
after  dilatation  the  patient  has  claimed  to  be  in  comfort,  with  no 
recurrence.  As  a  palliative  the  procedure  is  justifiable,  especially 
if  fissure  is  present. 

Gradual  dilatation  by  the  use  of  specula  of  increasing  size  or  of 
dilators  can  be  carried  out.  The  procedure  takes  several  weeks  and  is 
necessarily  very  painful.  If  this  method  is  carried  out,  air  dilatation 
with  Roberts'  dilator  (Fig.  216),  made  on  the  principle  of  Barnes' 
cervical  dilator  bag,  is  the  most  satisfactory.  The  hard-rubber 
dilators  cause  more  pain. 


Fig.  216. — Roberts'  dilator. 


Rapid  and  complete  dilatation  under  anesthesia  is  the  best 
method  when  safe  for  the  patient.  With  the  aid  of  a  skilled 
anesthetist  it  can  be  satisfactorily  performed  under  nitrous  oxid. 
Other  anesthetics  can  be  employed.  The  thumbs  must  be  inserted 
into  the  rectum  and  the  sphincter  dilated  gradually,  both  laterally  and 
anteroposteriorly.  All  spasm  must  be  overcome  and  the  sphincter 
thoroughly  relaxed.  Violence  must  not  be  employed.  An  opium 
suppository,  gr.  i  (0.065),  with  belladonna,  gr.  ^  (0.02),  should  be 
inserted  and  the  bowels  kept  closed  for  about  forty-eight  hours. 

Carbolic  Acid  Injection. — This  method  has  been  recommended 
in  order  to  produce  shrinking  of  the  piles  and  so  avoid  radical  opera- 
tion-.    It  should  not  be  performed  if  the  hemorrhoids  are  inflamed. 

The  following  solutions  for  injection  have  been  recommended : 

I^.     Acid,  carbolic.  (Calvert's) oij  |8 

Acid,  salicylic oss  2 

Sod.  bibor 5  j  4 

Glycerin  (sterile) q.  s.  o j  130. — M. 

(J.  P.  Tuttle.) 


HEMORRHOIDS,    PROLAPSE    OF    RECTUM;    FISSURE  585 

The  solution  should  be  syrupy  and  clear ;  if  white,  it  is  imperfect. 

The  average  injection  into  a  hemorrhoid  is  TTLv  (0.296).  Not  more 
than  TTLx  (0.592)  should  be  injected  into  two  to  three  hemorrhoids. 
After  the  injection  a  suppository  of — 


I^.     Opii  (pulv.) gr.  j 

Ext.  laelladonnse S^-  7 

lodoformi 8^-  ij 

Ol.  theob q.  s. 


065 
022 

13 
.— M. 


Carbolic  acid  and  glycerin,  equal  parts;  or  carbolic,  i ;  glycerin,  3; 
water  (distilled),  3,  have  been  employed. 

Inject  3  to  5  drops  with  a  hypodermic  syringe  into  the  center  of 
the  pile.  Care  must  be  taken  that  none  of  the  solution  drops  from 
the  needle  and  cauterizes  the  mucous  membrane.  An  enema  is  first 
given,  the  piles  cleansed  and  dried,  and  then  anointed  with  iodoform 
ointment  after  injection  with  carbolic. 

A  few  drops  of  a  i  per  cent,  cocain  solution  may  be  first  used 
subcutaneously  to  deaden  the  pain. 

It  is  preferable  to  inject  one  hemorrhoid  at  a  time.  Considerable 
pain  at  times  follows.  The  possible  dangers  are  ulcer,  abscess,  and 
fistulse.   There  is  some  danger  of  sepsis  and  cases  have  been  reported. 

Cauterization  with  Fuming  Nitric  Acid. — The  surrounding  parts 
are  covered  with  a  thick  layer  of  vaselin  except  the  pile  that  is  to  be 
treated.  This  is  painted  with  the  nitric  acid  by  means  of  a  small 
stick  or  glass  rod.  Care  must  be  taken  that  the  acid  touches  no  other 
spot.  The  pile  turns  a  grayish-green  color  as  a  result.  Iodoform 
ointment  or  vaselin  is  appHed  and  the  hemorrhoid  pushed  back  into 
the  rectuni.  Allingham  advises  carbolic  acid  as  a  substitute  for  the 
nitric  acid.    There  is  an  element  of  danger  from  sepsis  in  this  method. 

Ligature  of  hemorrhoids  under  anesthesia  without  removal  and 
then  allowing  them  to  slough  off  has  been  employed.  The  method 
is  not  to  be  recommended  for  obvious  reasons. 

Crushing. — ^The  hem.orrhoid  is  crushed  longitudinally  by  means 
of  a  special  instrument,  the  projecting  portion  cut  off,  and  pressure 
kept  up  for  about  a  minute.     This  technic  is  not  advised. 

Clamp  and  Cautery. — Each  pile  is  seized  with  a  volsellum  forceps 
and  drawn  well  down.  The  clamp  is  applied  to  embrace  its  base. 
The  portion  above  the  clamp  is  cut  off  with  scissors,  and  the  cautery 
iron,  heated  to  a  dull  red,  is  applied  to  the  stump  until  the  vessels 
are  well  seared.  Either  the  thermocautery  or  galvanocautery  can 
be  employed.  Excellent  results  have  been  secured  by  this  opera- 
tion. 

Ligature  and  Extirpation  ( Allingham' s  Operation). — Incision  is 
performed  at  the  base  of  each  pile  through  the  mucosa,  and  the 
pedicle  dissected  out.  This  is  ligatured  and  the  pile  cut  ofif  with 
scissors.  Some  operators  remove  every  alternate  hemorrhoid,  the 
rest  usually  shrinking  as  a  result  of  operation.     Others  incise  the 


586  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

mucous  membrane  above  the  base  of  the  pedicle  and  force  it  back 
hke  a  cuff.  After  hgature  and  removal  of  the  pile,  the  cuff  of  mucosa 
is  drawn  down  and  a  single  stitch  taken.  This  last  method  is  to  be 
recommended. 

Extirpation  and  Suture  {Whitehead's  Operation). — The  m^ucous 
membrane  containing  the  hemorrhoids  is  dissected  out,  the  incision 
frequentlv  encircling  the  anus.  The  piles  are  removed,  and  the 
mucosa,  being  loosened  up,  is  drawn  down  and  attached  by  sutures 
to  the  skin  at  the  anal  margin.  Stricture  or  incontinence  of  feces  are 
sequels  which  may  follow  this  operation.  Subsequent  treatment 
by  bougies  is  necessary  if  stricturing  be  feared  or  if  it  occur. 

In  these  operations  anesthesia  is  necessary,  and  dilatation  of  the 
sphincter  previous  to  removal  of  the  hemorrhoids. 

It  is  usually  customary  to  close  the  bowels  for  twenty-four  to 
forty-eight  hours  after  operation  by  means  of  opium  suppositories, 
though  Graser  opens  the  bowels  at  once. 

Gant's  Water  Infiltration  Method. — ^This  method,  devised  by  Sam- 
uel Gant,  is  of  special  value  in  cases  where  an  anesthetic  is  contra- 
indicated  or  when  the  patient  objects  to  its  employment.  With  a 
large  hvpodermic  sterile  water  is  injected  about  the  base  of  each 
hemorrhoid  in  the  submucosa,  producing  thorough  infiltration. 
An  incision  is  then  made  around  the  base  of  the  pile,  the  pedicle 
dissected  out,  the  latter  Hgatured,  and  the  pile  cut  off  with  scissors. 

Careful  preliminary  dilatation  of  the  sphincter  is  carried  out. 

Having  seen  this  operation  performed  by  its  originator  and  also 
the  ultimate  results,  I  can  recommend  it  as  excellent. 

Complications  of  Hemorrhoids. — Prolapse  of  the  Rectum. — 
Etiology. — Rectal  prolapse  is  a  fairly  frequent  complication  of  hemor- 
rhoids, though  it  may  occur  alone.  It  may  involve  the  mucous  mem- 
brane alone  or  all  the  coats  of  the  rectum  (procidentia  recti).  Among 
other  causes  of  prolapse  are  polypi,  vegetations,  tumors;  conditions 
tending  to  weaken  the  sphincters,  such  as  ulceration  or  operative 
incisions,  spinal  paralysis,  or  traumatism;  conditions  producing 
muscular  spasm,  such  as  worms,  dysentery,  phimosis,  cystitis,  cal- 
culus, enlarged  prostate,  or  stricture  of  the  urethra. 

In  some  cases  wdth  hemorrhoids,  the  prolapse  may  only  be  partial 
as  regards  the  circumference  of  the  rectum,  while  in  others  it  involves 
the  entire  circumference  and  there  is  a  scarlet  or  livid  mass  projecting 
from  the  anus.  An  internal  prolapse  of  the  rectum  may  occur,  in 
which  the  upper  part  descends  through  the  lower  part,  but  does  not 
appear  outside  the  anus.  It  is  probably  due  to  relaxation  of  the 
ligaments  of  the  rectum.  It  corresponds  rather  to  an  intussuscep- 
tion. 

Weakness  and  paralysis  of  the  sphincters  are  predisposing  factors. 

Prolapse  of  the  rectum  is  frequent  in  debilitated  children,  espe- 
ciallv  if  there  is  intestinal  catarrh  with  a  tendency  to  frequent  stools 
accompanied  by  straining.    Rectal  prolapse  occurs  in  elderly  people, 


hemorrhoids;  prolapse  of  rectum;  fissure  587 

also   in  cases  of  severe  constipation,  and  as  a  result   of   frequent 
pregnancies. 

Symptoms. — With  moderate  prolapse,  during  the  act  of  defeca- 
tion, a  protrusion  of  the  rectum  from  i  to  2  inches  long  appears 
outside  the  anus.  It  is  red  or  bluish  red  in  color  and  puckered  in 
appearance,  covered  with  some  mucus.  The  swelling  is  continuous, 
with  the  skin  on  one  side  and  with  the  mucous  membrane  on  the  other, 
and  is  arranged  in  folds  which  radiate  from  the  central  aperture 
toward  the  circumference. 

In  advanced  cases  the  mass  resembles  a  tumor  with  a  star-like 
opening  at  its  center,  and  the  color  is  a  paler  red  or  bluish.  With 
children  the  mass  generally  protrudes  only  when  at  stool ;  while  with 
adults  it  comes  down  more  readily  or  often  remains  constantly  down. 
At  first  it  is  spontaneously  reducible,  later,  easily  replaced  by  slight 
pressure,  and  finally  it  may  become  very  difficult  or  nearly  impossible 
of  reduction. 

It  often  becomes  inflamed  or  ulcerated,  and  in  old  cases  in- 
continence of  feces  may  occur. 

At  first  there  is  no  or  little  pain,  but  after  a  time  it  may  become 
quite  severe. 

There  is  a  tendency  for  the  prolapse  to  increase  in  size.  If  in- 
flammation occur,  there  will  be  fever  and  constitutional  disturbances. 

As  a  rule,  there  is  no  marked  bleeding  from  the  prolapse  itself, 
but  more  of  an  oozing.     Hemorrhage  from  associated  hemorrhoids 

mav  occur. 

Diagnosis. — This  is  made  from  the  appearances  described.  If 
operation  is  contemplated,  it  is  important  to  differentiate  between 
prolapse  of  the  mucosa  alone  or  of  the'  rectum.  In  the  latter  event 
the  peritoneum  may  be  involved  and  the  intestines  be  found  in 
the  prolapsed  portion. 

Prolapse  of  the  mucosa  is  not  as  firm  and  thick  to  the  feel,  the 
folds  of  the  mucous  membrane  radiate  from  the  orifice  to  the  circum- 
ference, and  the  opening  is  circular  and  patulous. 

With  prolapse  of  the  entire  wall  the  tumor  is  more   conic,  the 

"  walls  are  thick  and  firm,  the  orifice  is  slit-like.     When  the  mass  is 

pressed  between  the  fingers  gurghng  of  gas  in  a  contained  loop  of 

gut  may  sometimes  be  heard  and  resonance  obtained  on  percussion. 

In  some  cases  where  there  is  much  inflammatory  thickening 
it  is  difficult  to  differentiate.  In  following  out  treatment  this  possible 
danger  should  be  recognized  and  due  precaution  be  exercised. 

Internal  prolapse  is  more  difficult  to  recognize.  Digital  examina- 
tion of  the  rectum  is  necessary.  First  keep  the  finger  close  to  the 
anterior  wall  until  it  passes  into  a  cul-de-sac.  Withdraw  it  slightly 
and  examine  the  center  of  the  mass  until  an  orifice  is  found  into  which 
the  finger  or  a  bougie  can  be  passed  for  some  inches  into  the  rectum. 

It  may  be  necessary  for  the  patient  to  bear  down  during  ex- 
amination. 


588  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Treatment. — Predisposing  factors  should  be  eliminated,  hemor- 
rhoids, polypi,  etc.,  removed.  Cleanliness  after  defecation  should 
be  observed.  The  prolapse  should  be  replaced  with  the  patient 
preferably  in  the  knee-elbow  position.  The  mass  should  be  thor- 
oughly lubricated  with  vaselin  and  gently  pressed  into  the  rectum. 
If  a  considerable  portion  is  down,  a  large  flexible  bougie  can  be  cau- 
tiouslv  passed  into  the  bowel,  pushing  before  it  the  upper  part  of  the 
descended  gut,  and  pressure  (taxis)  should  be  employed  evenly  on 
the  other  surrounding  portions  with  the  fingers. 

When  the  prolapse  occurs  frequently,  a  rectal  supporter  should 
be  worn,  such  as  a  soft-rubber  ball  attached  to  the  anus  by  means 
of  a  belt  and  T-bandage.  A  supporter  can  be  improvised  by  em- 
ploying a  small  roll  of  gauze  covered  with  oiled  silk  and  attaching 
it  to  a  home-made  T-bandage. 

With  children  palliative  treatment  is  more  successful.  The 
cause  of  the  difficulty  should  be  investigated  and  removed  if  possible, 
such  as  a  polypus.  The  general  health  should  be  built  up,  mild 
laxatives  should  be  administered,  and  the  diet  regulated  to  secure 
easy  bowel  action  if  there  is  constipation.  If  diarrhea  is  a  factor,  it 
should  receive  treatment.  The  child  should  be  instructed  not  to 
strain  at  stool,  and  in  many  cases  it  is  wise  to  have  him  defecate  in 
the  knee-elbow  posture  over  a  vessel  to  prevent  prolapse  as  much  as 
possible,  or  in  the  vSims  posture,  even  at  the  expense  of  soiling  the 
bedding  or  clothing,  which  can  be  easily  changed. 

If  prolapse  occurs,  it  should  be  w^ashed  with  cold  water  or  weak 
boric  acid  solution  or  an  astringent  alum  solution,  5j  (4.0)  alum  to 
oviij  (250  cc.)  water,  smeared  with  vaselin,  and  gently  returned  into 
the  anus.  After  this  the  patient  should  remain  in  the  recumbent 
position  for  about  half  an  hour,  preferably  lying  on  the  abdomen. 

Radical  measures  must  frequently  be  adopted.  Cauterization 
of  the  prolapsed  portion  with  fuming  nitric  acid  or  acid  nitrate  of 
mercury,  as  suggested  by  Allingham,  or  (preferably)  with  the  thermo- 
cautery under  anesthesia,  has  benefited  or  even  cured  cases.  After 
cauterization  the  prolapsed  part  should  be  lubricated  and  returned 
into  the  anus.  Strictures  are  occasionally  produced  by  this  pro- 
cedure. 

Other  methods  have  proved  successful,  such  as  excision  of  elliptic 
portions  of  the  mucous  membrane  with  subsequent  suture ;  extirpa- 
tion of  the  prolapsed  portion ;  revision  or  narrowing  of  the  caliber  of 
the  rectum;  suspension  of  the  prolapsed  rectum  by  attaching  its 
mesentery  to  the  abdominal  wall ;  or  suspension  of  the  lower  end  of 
the  sigmoid  flexure. 

Fissure  of  the  Anus. — This  condition  quite  frequently  occurs  with 
hemorrhoids.  The  fissure  consists  of  an  oblong  tear  of  the  mucous 
membrane  of  the  anus,  which  gives  rise  to  pain  and  spasmodic  con- 
traction of  the  sphincters.  Some  fissures  are  slight  abrasions  or  they 
may  be  fairly  large  and  deep.     The  edges  may  appear  healthy,  or  be 


hemorrhoids;  prolapse  oe  rectum;  fissure  589 

inflamed  or  indurated.  Those  of  longer  duration  present  the  ap- 
pearance of  an  ulcer.     In  fact,  they  are  classified  as  irritable  ulcer. 

Anal  fissure  is  usually  caused  by  an  injury  or  tearing  of  the 
mucosa  at  the  edge  of  the  anus.  Excessive  straining  or  the  passage 
of  dry  hard  scybalae  are  factors.  It  is  more  common  among  women. 
The  fissure  may  occur  in  any  location,  though  most  frequently  at  the 
posterior  portion  of  the  anus.  It  generally  lies  parallel  and  close  to 
the  external  sphincter,  though  it  may  be  higher  up  near  the  internal 
sphincter  or  above  it. 

Symptoms. — Severe  pain  in  the  rectum  during  defecation  and  at 
times  tenesmus,  persisting  for  a  time  thereafter,  are  present.  The 
pain  may  be  very  severe  in  character,  so  that  the  patient  dreads  to 
have  a  stool,  and  increased  constipation  results. 

A  small  fissure  over  the  external  sphincter  usually  causes  greater 
disturbance  than  a  larger  one  higher  up.  There  may  be  reflex 
irritation  of  the  bladder  and  a  discharge  of  pus  and  blood  from  the 
rectum.  From  the  pain  and  suffering  the  nervous  system  may  become 
affected. 

Diagnosis. — This  is  made  from  the  symptoms  and  by  local  exam- 
ination. The  patient  should  lie  on  the  left  side  and  be  told  to  bear  down. 
On  opening  the  anus  with  the  finger  and  thumb,  a  fissure  (crack)  or 
small  club-shaped  ulcer  can  frequently  be  seen.  It  may  be  red  and 
inflamed  or,  if  more  chronic,  of  a  gray  color  wdth  indurated  edges. 
The  pain  may  be  so  severe  that  before  local  examination  it  may  be 
necessary  to  introduce  a  suppository  of  cocain,  gr.  \  (0.016).  Rarely 
an  anesthetic  may  be  required. 

For  a  fissure  higher  up,  examination  with  the  speculum  may  be 
necessary. 

Treatment. — Hemorrhoids  or  polypi,  if  present,,  should  be  re- 
moved. The  dilatation  of  the  sphincter  performed  during  this  opera- 
tion and  removal  of  the  cause  of  the  fissure  will  usually  cure  the  case. 
An  incision  through  the  base  of  the  ulcer  can  be  made  at  the  same 
operation  as  a  precaution. 

Recent  fissures  are  at  times  cured  without  operation.  The  patient 
should  be  in  the  recumbent  position,  hot  lead-and -opium  lotion  can 
be  applied  externally  to  the  anus  if  much  pain,  as  heat  relieves  pain 
and  spasm. 

The  following  ointment  and  suppository  are  of  value  for  the  same 
purpose : 

I^.     Ext.  conii oij  8l 

Olei  ricini oiij  12 

Ung.  lanol q.  s.  oij  60I. — M. 

Ft.  unguentum. 

IJ.     Ext.  belladonnae   gr-  i  '02 

Ext.  opii gr.  ^  |o3 

01.  theob gr.  XV  i|. — M. 

One  suppository. 


590  DISEASES   OF  THE    STOMACH    AND   INTESTINES 

Locally,  the  fissure  can  be  touched  with  silver  nitrate  solution  (I 
have  used  the  pure  silver  nitrate  stick  twice  a  week),  varying  in 
strength  from  gr.  lo  to  30  (0.6-2.0)  to  the  ounce  (30.0)  of  water 
every  two  to  three  days ;  on  the  alternating  days  a  5  per  cent,  cocain 
solution  can  be  carefully  applied,  only  a  few  drops;  or  the  follow- 
ing ointment  can  be  alternated  with  the  silver  application,  or  sub- 
stituted for  a  time: 


or 


I^.     Ichthyol gr.  xxx  2 

Lanolin 5ij  8 

Petrolati q.  s.  5  j  30 

Ft.  unguentum. 


I^.     Hydrarg.  chlo.  mit gr.  xv  i 

Pulv.  opii  ) 

Kxt.  belladonnae  / ^^  f'"^ 

Petrolati oss  15 

Ft.  unguentum. 


-M. 


3 
.— M. 


Gradual  dilatation  of  the  sphincter  without  anesthesia,  as  de- 
scribed under  Hemorrhoids,  especially  with  Roberts'  dilator,  is  some- 
times employed,  but  this  procedure  is  painful. 

Dilatation  of  the  sphincter  under  anesthesia  is  often  found  cura- 
tive of  obstinate  cases.  Nitrous  oxid  is  a  valuable  anesthetic  for  this 
purpose. 

Some  recommend  infiltration  of  the  fissure  with  a  hypodermic 
of  I  per  cent,  cocain,  and  a  free  incision  through  its  base  to  the 
sphincters. 

An  incision  of  the  fissure  under  anesthesia,  combined  with 
sphincter  dilatation,  may  be  required. 

Proctitis. — If  proctitis  is  present  with  hemorrhoids,  it  must  re- 
ceive appropriate  treatment,  as  described  under  the  section  on  that 
subject. 


CHAPTER  XXIX 
APPENDICITIS 

(Svnonvms. — Inflammation  of  the  Vermiform  Appendix;  Perityphlitis;   Appen- 
dicular Inflammation;  Scolecoiditis.) 

Inflammatory  conditions  involving  the  right  ihac  region  have 
been  called  by  a  variety  of  names:  Iliac  phlegmon;  typhHtis  (in- 
flammation of  the  cecum) ;  perityphlitis  (inflammation  of  the  cover- 
ing of  the  cecum);  and  paratyphlitis  (inflammation  of  the  retro- 
peritoneal tissue  behind  the  cecum).  Though  typhHtis  was  considered 
to  be  the  cause  of  most  of  the  inflammations  in  the  right  iliac  fossa, 
modern  investigation  has  demonstrated  that  appendicitis  is  the  chief 
factor. 

Some  go  so  far  as  to  state  that  even  stercoral  typhlitis  (an  inflam- 
mation due  to  fecal  accumulation)  does  not  exist.  This  is  an  error,  as 
G.  A.  McWilliams,!  though  admitting  it  to  be  rare,  shows  that  an 
acute  or  chronic  primary  typhHtis  may  occur  independently  of  ap- 
pendicitis, dysentery,  tuberculosis,  actinomycosis,  or  cancer;  and 
that  it  may  be  either  idiopathic  in  origin  or  due  to  coprostasis. 

Autopsy  reports  and  findings  at  operations  have  confirmed  this 
opinion.  Cecal  disease  may  go  on  to  ulceration  and  perforation, 
with  the  formation  of  perityphlitic  abscess  or  general  peritonitis, 
while  the  appendix  remains  normal.  Howard  Kelly  has  reported 
14  cases  presenting  primary  lesions  in  the  cecum,  the  appendix 
being  normal. 

Over  90  per  cent,  of  inflammations  are  due  to  the  appendix ;  the 
rest  to  the  cecum. 

The  symptoms  of  typhHtis  are  usually  indistinguishable  from 
those  of  appendicitis  and  the  indications  for  operation  are  the  same. 
The  literature  on  appendicitis  is  enormous,  and  I  shall  only  mention 
the  names  of  a  few  of  those  specially  identified  with  the  operative 
technic  and  investigation  of  appendicitis,  namely:  Reginald  Fitz, 
Richardson,  Sands,  McBurney,  Bryant,  BuH,  Weir,  Fowler,  Hartley, 
Dawbarn,  R.  T.  Morris,  Wyeth,  Blake,  Brewer,  Hotchkiss,  Deaver, 
and  Howard  Kelly. 

Position  of  the  Appendix.— It  takes  its  origin  generally  from 
the  posterior  and  median  surface  of  the  cecum,  corresponding  to 
McBurney's  point  (i^  inches  from  the  anterosuperior  spine  of  the 
ileum) ,  on  a  line  drawn  from  the  spine  to  the  umbilicus.  The  average 
length  is  from  3  to  5  inches,  but  it  may  vary  markedly.  The  statistics 
as  to  its  direction  are  quite  variable.  It  may  point  downward  and 
1  Annals  of  vSurgery,  June,  1907. 

591 


592  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

inward,  downward  behind  the  cecum,  or  upward,  upward  and  inward, 
transversely  inward,  or  outward.  In  many  cases  the  appendix  is 
quite  long,  and  the  position  and  length  thus  explain  the  variable 
locations  of  adhesions  or  abscess.  It  may,  therefore,  come  in  contact 
with  the  male  bladder  or  rectum,  with  the  uterus  or  right  tube  and 
ovary,  or  even  the  left  tube,  or  with  the  small  intestine,  or  it  may 
pass  up  as  high  as  the  liver  or  right  kidney,  even  to  the  left  rectus, 
and  close  to  the  spleen.  It  has  been  found  behind  the  peritoneum 
with  no  peritoneal  covering.  Bryant  has  reported  it  outside  the 
peritoneal  cavity  in  3  cases.  It  has  been  found  quite  frequently  in 
hernial  sacs,  and  on  several  occasions  in  the  scrotum.  It  quite  fre- 
quently hangs  free  in  the  abdominal  cavity. 

Peculiarities  of  the  Appendix. — The  lumen  of  the  canal  is 
extremely  narrow;  the  organ  is  bottle  shaped,  the  narrowest  part 
being  near  the  entrance  into  the  cecum.  Gerlach's  valve,  a  redupli- 
cation of  the  mucous  membrane  of  the  appendix  near  its  origin  from 
the  cecum,  makes  the  entrance  of  material  more  difficult,  and  also  its 
exit.  The  circular  muscular  fibers  are  somewhat  scanty.  These 
factors  tend  to  produce  stagnation  and  predispose  to  infection. 

There  are  many  lymph-follicles  (adenoid  tissue)  in  the  appendix, 
which  usually  persist  up  to  the  age  of  about  thirty  and  then  begin  to 
retrograde,  so  that  infection  is  easy,  as  in  the  tonsils.  In  many  cases 
the  appendix,  is  completely  surrounded  with  peritoneum,  in  some  it  is 
only  partially  covered,  and  the  uncovered  portion  is  in  direct  contact 
with  the  retroperitoneal  connective  tissue,  which  readily  accounts 
for  the  so-called  perityphlitic  abscess.  The  appendix  has  a  mesen- 
tery of  its  own,  as  a  rule,  the  meso-appendix,  but  it  is  not  constantly 
present.  It  rarely  reaches  up  to  the  tip,  but  usually  only  one-half 
to  two-thirds  of  the  distance.  It  is  believed  to  have  some  influence 
on  the  shape  of  the  appendix,  as  when  it  is  relatively  short  the  latter 
may  be  bent.  Crile,^  in  an  analysis  of  1000  cases  of  appendicitis, 
found  that  in  a  large  percentage  there  was  a  short  meso-appendix, 
causing  fixation  of  the  proximal  part  and  leaving  the  distal  end  free, 
which  tended  to  cause  the  appendix  to  fold  on  itself  and  interfered 
with  the  circulation  (an  anatomic  angulation). 

The  blood-supply  of  the  appendix  is  quite  scanty.  The  ves- 
sels (the  appendicular  and  a  few  cecal  branches)  Fowler  believes 
to  be  functionally  nearly  end  arteries,  the  most  abundant  being  from 
the  vessels  (the  appendicular)  in  the  meso-appendix,  so  that  the 
vascular  supply  of  the  tip  of  the  organ  is  poor. 

In  females,  Clado^  holds  that  there  is  a  third  source  of  blood- 
supply  from  a  vessel  passing  through  the  appendiculo-ovarian  liga- 
ment (a  fold  of  peritoneum  passing  from  the  meso-appendix  to  the 
broad  ligament),  and  this  possibly  explains  why  appendicitis  is  less 
common  in  women,   on  account  of  the  superior  vascular  supply. 

1  Ohio  State  Medical  Journal,  June,  1907. 

2  Compt.  Rend.  Soc.  Biol.,  1897,  vol.  iv,  p.  133. 


APPENDICITIS  593 

Fowler  holds  that  the  blood-vessels  may  be  primarily  affected. 
Misplacement  and  malformation  of  the  appendix  may  also  have  an 
influence.  The  peculiar  anatomic  conformation  of  the  appendix 
may  predispose  to  infection. 

Etiology. — The  chief  cause  of  appendicitis  is  bacterial  invasion, 
the  most  common  of  which  present  is  the  Bacterium  coli  commune. 
As  a  rule,  the  infection  is  a  mixed  one,  streptococci  being  frequently 
associated.     The  proteus  vulgaris  has  been  present. 

The  Diplococcus  pneumoniae,  staphylococci,  the  anaerobes,  and 
the  influenza  bacillus  have  been  found.  These  are  the  most  fre- 
quent varieties  and  are  found  both  in  the  appendix,  appendical 
abscess,  and  in  the  general  peritoneum  (fluid  of  the),  if  peritonitis 
is  present.  In  isolated  cases,  appendicitis  is  believed  by  some  to  be 
a  local  expre^ssion  of  a  general  infection,  as  associated  with  scarla- 
tina, measles,  rotheln,  small-pox,  chicken-pox,  parotitis,  influenza, 
and  acute  articular  rheumatism.  It  has  accompanied  suppurative 
tonsillitis. 

Typhoid,  dysentery,  and,  more  rarely,  tuberculosis  may  be  causes. 
Actinomycosis  has  also  been  demonstrated  to  have  produced  it. 

Traumatism^  or  injury  from  lifting  have  been  given  as  causes,  but 
probably,  if  appendicitis  occurs  as  a  sequel,  the  organ  was  previously 
diseased  or  damaged,  or  the  symptoms  might  be  due  to  a  circum- 
scribed traumatic  peritonitis. 

Constipation  as  a  factor  in  the  production  of  appendicitis  is  a 
question  of  dispute.  Fitz  and  Fowler  believed  that  in  the  majority 
of  patients  the  bowels  acted  regularly  previous  to  the  attack,  and 
Riegel  holds  that  constipation  and  diarrhea  have  no  bearing  on  the 
subject.  Though  unquestionably  many  patients  suffering  from  con- 
stipation never  suffer  from  appendicitis,  there  is  one  .type  of  case  in 
which  it  may  be  a  factor,  namely,  patients  in  whom  there  is  a  tend- 
ency to  fecal  accumulation  in  the  caput  coli  and  lower  ileum,  with 
resulting  appendix  symptoms,  probably  from  circulatory  interference, 
pressure,  blocking  of  the  appendix  opening,  and  catarrh  secondary  to 
a  slight  catarrh  of  the  cecum.  I  have  seen  several  such  cases  in 
which  there  were  the  typic  symptoms,  which  rapidly  subsided  after 
thorough  bowel  irrigation,  ice-bag,  and  later  cathartics  and  sub- 
sequent treatment  of  the  constipation,  with  no  subsequent  attacks 
during  eight  or  ten  years'  observation.  To  this  same  class  belong 
the  rare  type  of  typhlitis  due  to  stercoral  ulcer  to  which  McWilliams 
refers. 

Dietetic  indiscretions,  in  so  far  as  they  are  productive  of  intestinal 
putrefaction  or  fermentation  with  increased  bacterial  activity,  might 
be  a  factor  in  producing  an  acute  attack  in  an  appendix  already 
damaged.  Intestinal  catarrh,  involving  the  caput  coli,  in  my  own 
experience  has  been  the  direct  cause  of  the  catarrhal  type  of  appendi- 
citis. 

^  Deaver,  New  York  Medical  Journal,  June  15,  1907. 
38 


594  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Entozoa,  such  as  the  trichocephalus  dispar,  oxyuris  vermicularis, 
ascaris  lumbricoides,  tapeworm,  and  bilharzia,  have  been  factors  in 
the  production  of  appendicitis.  Movable  kidney,  through  pressure 
on  the  mesenteric  vein,  has  been  given  as  a  frequent  cause  by  Ede- 
bohls.  This  condition  is  associated  with  splanchnoptosis,  and  the 
circulatory  changes  from  malposition  of  the  viscera  are  more  probably 
factors.  These  conditions  occur  most  frequently  with  women,  yet 
appendicitis  is  less  frequent  in  the  female. 

Foreign  bodies  entering  the  appendix,  such  as  grape  seeds,  cherry 
stones,  pits,  pins,  buttons,  gall-stones ,  etc.,  are  rare  causes  of  appendi- 
citis. 

Fecal  concretions  are  found  frequently  and  have  been  mistaken 
for  foreign  bodies.  Probably  normally  soft  fecal  matter  enters  and  is 
expelled  from  the  appendix.  The  fecal  concretions  are  generally  hard 
in  character  from  absorption  of  water  and  are  thickened  by  mucus. 
C.  B.  Lockwood  has  demonstrated  that  in  many  cases  they  consist 
of  an  inspissated  mass  of  bacteria.  It  is  easy  to  understand  how  such 
concretions,  if  of  large  size,  can  exert  pressure  and  even  be  productive 
of  ulceration,  especially  if  there  be  any  abnormal  condition  in  the 
appendix.  They  have  been  found  in  one-third  to  nearly  one-half  of 
the  cases.  Small  concretions  might  remain  in  an  appendix  without 
harm.     They  generally  lie  near  the  end  (tip). 

Right  tubo-ovarian  inflammation  may  be  a  factor  in  the  produc- 
tion of  appendicitis. 

i4g^.— Appendicitis  seems  most  frequent  between  ten  and  thirty 
years,  Fitz  stating  that  50  per  cent,  occur  before  the  twentieth  year, 
and  Einhorn  60  per  cent,  between  sixteen  and  thirty  years.  It  has 
been  reported  as  early  as  the  seventh  week,  but  rarely  before  the 
third  year. 

Sex. — Men  suffer  from  appendicitis  much  more  frequently  than 
women  (from  2  to  3  or  more  to  i). 

Varieties. — I  will  describe  both  the  pathologic  and  clinical  types 
of  appendicitis. 

From  a  pathologic  standpoint,  the  following  seems  the  best  classi- 
fication : 

1.  Acute  catarrhal  appendicitis,  in  which  the  mucous  membrane 
is  involved,  being  swollen  and  edematous,  the  submucosa  injected 
with  excessive  secretion  of  mucus  or  mucopus. 

This  type  is  mild,  and  the  appendix  drains  into  the  cecum  with 
perfect  recovery  (endo-appendicitis,  Fowler). 

2.  Acute  Diffuse  Appendicitis. — ^There  is  inflammation  of  the 
mucosa  and  thickening  of  the  entire  organ,  which  is  rigid,  tense,  and 
infiltrated.     By  some  it  is  classified  as  catarrhal,  but  this  is  incorrect. 

The  peritoneal  surface  is  hyperemic.  There  may  be  erosions  or 
small  ulcers  and  a  fecal  concretion.  There  may  be  mucus  or  muco- 
purulent material  in  the  lumen,  or  in  some  cases  it  may  be  narrowed 
or  obliterated. 


-    APPENDICITIS  595 

This  type  sometimes  hangs  free  in  the  abdomen,  but  more  gener- 
ally is  adherent  to  the  adjacent  peritoneal  structures,  and  is  character- 
ized by  the  surgeons  clinically  as  acute  nonsuppurative  appendicitis. 
It  may  resolve  without  operation. 

On  the  other  hand,  this  pathologic  type  may  be  productive  of 
abscess  or  perforation,  when  it  would  be  placed  under  a  different 
class  by  the  surgeons. 

3.  Purulent  or  Suppurative  Appendicitis. — This  is  a  more  advanced 
stage  than  the  former.  There  is  a  definite  pus-sac  formed  by  the 
appendix.  This  type  may  also  perforate  and  cause  local  abscess  or 
general  peritonitis. 

4.  Gangrenous  Appendicitis. — This  is  characterized  by  necrosis, 
local  or  general.  The  tip  is  most  frequently  involved  or  the  entire 
organ. 

5.  Chronic  Appendicitis. — This  may  follow  the  acute,  or  the 
process  may  be  slow  and  gradual  from  its  incipiency.  In  some  cases 
the  changes  have  been  found  to  be  very  slight,  merely  the  evidence  of 
a  chronic  catarrh  of  the  mucosa,  probably  an  extension  from  a  chronic 
catarrh  of  the  cecum.     At  times  stenosis  is  present. 

On  the  other  hand,  the  organ  has  been  found  firm,  slightly  en- 
larged and  thickened,  the  mucosa  thickened,  and  the  lumen  narrowed. 
In  some  cases  there  may  be  a  stenosis,  with  formation  of  a  cyst. 
In  others  there  are  concretions  or  erosions,  or  partial  obliteration  of 
the  lumen;  or  the  appendix  may  become  converted  into  a  cord-like 
structure,  embedded  in  a  mass  of  thick  peritoneal  adhesions. 

6.  Obliterative  Appendicitis-. — A  gradual  involution  process  occurs 
in  many  individuals.  The  tube  is  thickened,  the  peritoneal  surface 
smooth;  the  distal  portion  of  the  lumen  may  be  entirely  obliterated, 
and  the  organ  becomes  sclerotic  and  shrunken.  Ribbert  found 
these  changes  in  more  than  50  per  cent,  of  subjects  over  sixty 
years  of  age.     Normal  involution  seems  to  present  no  symptoms. 

From  a  clinical  standpoint  the  physician  will  find  several  types 
of  acute  and  chronic  appendicitis,  readily  deduced  from  the  pathologic 
classification. 

1.  Acute  Simple  Catarrhal  Appendicitis  (Endo-appendicitis). — 
A  catarrh  of  the  mucosa  of  the  appendix.  This  is  of  mild  type  and  is 
often  secondary  to  a  colitis  or  to  fecal  impaction  in  the  cecum. 
Unless  there  is  occlusion,  the  inflammatory  products  usually  drain  out 
(non-suppurative  type,  with  complete  cure).  There  may  be  recur- 
rent attacks. 

2.  Acute  Non-suppurative  Appendicitis  (Sometimes  Incorrectly 
Characterized  as  Acute  Catarrhal). — ^The  description  is  that  of  the 
Acute  Diffuse  Appendicitis,  the  entire  organ  being  involved. 

There  is  fibrinous  exudation  agglutinating  the  appendix  to  neigh- 
boring structures,  and  the  meso-appendix  is  thickened  and  inflamed. 
There  may  be  kinking  or  torsion  of  the  organ,  stricturing,  or  even 
obliteration,  and  fecal  concretion  may  be  left  within  it. 


596  DISEASES    OF    THE    STOMACH    AXD    INTESTINES 

These  cases  often  escape  operation  and  may  not  have  a  recur- 
rence, but  there  is  great  habihty  of  the  latter. 

3.  Chronic  Appendicitis. — This  may  follow  the  acute,  or  the  proc- 
ess be  slow  and  gradual  from  the  start.  The  chronic  catarrhal  cases 
ma}'  exhibit  but  little  change,  or  the  appendix  may  be  thickened, 
the  mucosa  thick  and  hyperemic,  and  its  lumen  narrowed,  obliter- 
ated, or  strictured. 

A  fecal  concretion  may  remain  within  it.  It  may  present 
adhesions.  It  may  follow  an  acute  attack  or  be  chronic  from 
the  onset. 

These  three  types  are  characterized  by  absence  of  perforation, 
gangrene,  or  abscess  formation;  though  type  2  may  progress  to  type 
4,  with  resulting  abscess  or  perforation. 

4.  Acute  Suppurative  Appendicitis  {Formation  of  Abscess). — 
Of  this  W'C  have  two  clinical  types,  the  pathologic  purulent  appendici- 
tis (the  appendix  distended  wdth  pus) ,  on  the  verge  of  perforation,  or 
an  inflamed  appendix  enclosed  in  an  abscess-cavity  containing  a 
varying  amount  of  foul  pus.  The  walls  of  the  cavity  are  formed 
by  adjacent  peritoneal  surfaces,  coils  of  intestines,  cecum,  and  omen- 
tum bound  together  by  adhesions. 

The  appendix  lying  in  the  abscess-cavity  is  congested  and  swollen, 
and  may  or  may  not  be  perforated  or  present  areas  of  gangrene. 
It  may  be  adjacent  to  the  cecum  or  intestines  or  reach  into  the  pelvis 
to  the  bladder  or  tubes  and  ovaries.  Perforation,  when  present,  is 
generally  near  the  free  end  of  the  appendix. 

5.  Gangrenotis  Appendicitis. — The  appendix  is  congested,  swollen, 
thick,  and  red,  with  gangrenous  areas  of  greenish-black  color  and 
usually  already  perforated.  It  is  marked  by  the  absence  of  pro- 
tective peritoneal  adhesions. 

There  may  be  a  fatal  septic  peritonitis  before  perforation  of  the 
appendix.  Patches  of  fresh  fibrin  may  be  present  with  serous 
or  bloody  turbid  serum  in  the  peritoneal  cavity  or  adhesions  with 
pus. 

The  condition  is  an  acute  gangrene  due  to  thrombosis  and  oc- 
clusion of  the  blood-vessels.  If  the  case  is  more  chronic,  some  plas- 
tic peritonitis  may  be  present. 

A  purulent  appendix,  an  acute  diffuse  appendicitis,  or  a  concre- 
tion may  ulcerate  through,  so  that  any  of  these  types — including 
the  gangrenous — may  be  classified  as  perforative  appendicitis. 

6.  Harmful  Involution  of  the  Appendix  (Morris). — The  vermiform 
appendix  normally  undergoes  an  involution  process  with  replace- 
ment of  the  lymphoid,  mucous,  and  submucous  coat  by  connective 
tissue.  R.  T.  Morris^  notes  that  the  ner\'e-filaments  persist  longer 
than  other  structures,  and  contraction  of  the  connective  tissue  in 
some  cases  irritates  these  nerA'e-filaments,  so  that  irritation  of  the 
ganglia  of  the  bowel  (Auerbach's  and  Meissner's  plexuses)  ensues  and 

1  Medical  Record,  April  6,  1907. 


APPENDICITIS 


597 


causes  disturbances  in  the  nearby  intestines.  This  condition  he 
characterizes  as  "fibroid  degeneration  of  the  appendix."^ 

The  appendix  is  at  no  time  the  seat  of  acute  or  chronic  infection, 
and  the  condition  is  characterized  by  intestinal  dyspepsia  and  other 
definite  symptoms  which  will  be  described  later.  The  involution 
may  be  symmetric  or  nodular  (Figs.  217-219),  and  occurs  most 
markedly  toward  the  distal  extremity. 

Symptoms  of  Acute  Appendicitis. — The  symptoms  of  acute  ap- 
pendicitis are  modified  by  the  character  of  the  lesion,  whether  it  is  a 
simple  catarrh,  an  appendicitis  with  the  production  of  adhesions,  a 
pus  cavity,  or  of  the  acute  gangrenous  type. 

In  general  the  cardinal  symptoms  of  acute  appendicitis  are  as 
follows : 


Fig.   217. — Symmetric  involution   of 
appendix  (Morris). 


Fig.  218. — Nodular  involution  of  ap- 
pendix (Morris). 


1.  Sudden  pain  in  the  abdomen  in  the  right  iliac  region,  or  at 
times  epigastric  or  umbilical,  which  soon  or  gradtially  localizes  in  the 
right  iHac  fossa.  Pains  are  continuous,  increasing,  or  only  exacerba- 
tions of  pain. 

2.  Tenderness  or  pain  on  pressure  in  the  right  iliac  region  at 
McBurney's  point.  Often  an  area  of  resistance  due  to  tumor  or 
to  muscular  rigidity. 

3.  Fever  of  moderate  or  severe  type. 

4.  Gastro-intestinal  disturbances  may  be  present,  such  as  nausea 
or  vomiting,  and  frequently  constipation. 

1  American  Journal  of  Surgery,  October,  190Q. 


598 


DISEASES   OF  THE   STOMACH  AND   INTESTINES 


5.  In  the  septic  gangrenous  type  I  have,  in  a  fairly  large  percentage 
of  cases,  observed  a  toxemic  type  of  diarrhea^  with  general  abdominal 
pains  at  times,  as  the  initial  symptom,  before  localization  of  the 
appendix  pain.  This  is  evidently  of  septicemic  character  and  has 
not  to  my  knowledge  heretofore  been  referred  to  as  a  symptom. 

6.  In  some  cases  the  thighs  and  knees  are  flexed. 

Pain. — The  pain  may  be  sudden  and  A^iolent,  or  at  times  inter- 
mittent and  cramp-like,  or  even  of  a  gnawing  character  or  a  dull  ache. 


Fig.  219. — Transverse  section  of  the  appendix,  showing  replacement  of  the  inner 
coats  by  connective  tissue  (Morris). 

Sudden  and  violent  pain  in  the  initial  stage  does  not  by  any  means 
mean  perforation,  unless  other  symptoms  are  associated.  In  about 
one-half  the  cases  the  pain  begins  in  the  right  iUac  fossa ;  it  may 
commence  in  the  epigastrium,  around  the  iimbihcus,  or  even  be 
diffuse,  but  gradually  becomes  localized  within  twelve  to  twenty- 
four  or  thirty-six  hours,  and  usually  sooner. 

At  times  the  pain  is  of  a  coUcky  type  (the  so-called  appendicular 

1  Rudolph  Schmidt  assumes  that  the  changes  from  normal  in  the  intestinal 
flora  of  the  feces,  which  occurs  in  appendicitis,  may  explain  diarrhea  in  the 
early  development  of  this  disease;  or  possibly  acute  enteritis  from  dietary  in- 
discretion may  be  the  cause  (Pain,  by  Rudolph  Schmidt).  The  type  of  diar- 
rhea wnth  gangrenous  appendix  seems  to  the  author  peculiarly  septic  and  is 
relieved  by  appendectomy. 


APPENDICITIS 


599 


colic,  supposed  by  some  to  be  due  to  constriction  of  the  appendix 
in  forcing  out  mucus  through  a  lumen  nearly  occluded).  Pain  is 
increased  on  moving.  It  is  often  relieved  by  flexing  the  knees  and 
thighs,  especially  the  right  thigh,  and  so  relaxing  the  abdomen. 
This  position  is  at  times  assumed  by  the  patient. 

Palpation  of  the  Appendix. — Though  some  surgeons  believe  this 
to  be  an  important  procedure  to  render  the  diagnosis  certain,  Treves 
and  lyockwood  are  very  skeptical  regarding  the  possibility  of  mapping 
out  this  organ.  In  the  chronic  cases  palpation  is  of  value,  and  the  posi- 
tion and  condition  of  the  appendix  can  often  be  determined  thereby. 

In  acute  appendicitis  the  methods  of  forcible  palpation  recom- 
mended often  necessitate  the  use  of  considerable  pressure,  and  I 
believe  the  procedure  highly  dangerous.  In  the  initial  stages  of 
acute  appendicitis  it  is  often  impossible  to  at  first  determine  the 


Fig.  220. — A,  McBurney's  point,  and  B,  R.  T.  Morris'  point  (lumbar  ganglia)  in 

appendicitis. 

character  of  the  attack,  and  traumatism  in  some  cases  can  precipitate 
a  rupture. 

In  the  acute  cases  gentle  palpation^  only  should  be  used. 

Muscular  Rigidity. — There  is  usually  rigidity  of  the  right  rectus 
muscle  of  varying  intensity. 

Tenderness  on  Pressure. — This  occurs  at  McBurney's  point  and  is 
of  varying  intensity,  also  at  Morris'  point,  and  Blumberg  describes 
a  new  symptom.  There  are  two  points  of  great  diagnostic  value  in 
appendicitis:  tenderness  at  McBurney's  point  and  at  Morris'  point 
(over  the  right  lumbar  ganglia). 

McBurney's  Point. — If  a  line  be  drawn  from  the  anterior  superior 

1  Percussion,  according  to  Rudolph  Schmidt,  will  often  demarcate  the  area 
of  pain  better  than  will  palpation. 


6oO  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

spine  of  the  right  ileum  to  the  umbiHcus,  a  point  i  J  inches  from  the 
spine  along  this  is  known  as  McBurney's  point;  and  deep-seated 
tenderness  on  pressure  over  this  point  is  diagnostic  of  appendical 
inflammation  when  taken  in  consideration  with  other  symptoms 
(Fig.  220).     Deep  pressure  also  often  causes  reflex  epigastric  pain. 

Mere  superficial  tenderness  means  irritation  of  the  sensory  nerves 
of  the  abdominal  wall  due  to  hysteria,  etc. 

Munro's  point  is  slightly  further  out,  where  the  same  line  crosses 
the  outer  border  of  the  rectus. 

Morris' Point. — "Take  another  point  on  this  same  line,  but  i^ 
inches  from  the  navel, ^  which  lies  over  the  right  lumbar  gangUa  of  the 
svm pathetic  system,  and  we  have  another  point  of  diagnostic  value 
when  tenderness  on  pressure  is  located  in  this  region. 

"  I .  In  the  early  stages  of  an  acute  infective  process  of  the  ap- 
pendix, the  right  lumbar  ganglia  are  not  tender.  (The  left  lumbar 
ganglia  may  be  described  for  diagnostic  purposes  as  lying  ih  inches 
to  the  left  of  the  navel.)  Under  these  circumstances  the  point  here 
described  is  of  secondary  importance,  while  McBurney's  point  is 
of  prime  consequence. 

"2.  A.  When  an  acute  inflammatory  process  of  the  appendix 
has  subsided,  leaving  a  mucous  inclusion  or  scar  tissue,  there  may 
be  no  tenderness  on  pressure  at  McBurney's  point,  but  there  is  ten- 
derness at  the  point  here  described  and  no  tenderness  at  the  point  of 
the  left  lumbar  ganglia. 

"5.  When  the  appendix  is  undergoing  an  involution  proc- 
ess, with  replacement  of  its  lymphoid  coats  by  connective  tissue, 
digestive  disturbances  and  various  local  neuralgias  may  be  due 
to  irritation  of  nerv'e-filaments  entrapped  in  the  new^  connective 
tissue.  There  may  be  no  tenderness  at  McBurney's  point,  but  there 
is  persistent  tenderness  at  the  point  here  described.  There  is  no 
tenderness  at  the  point  of  the  left  lumbar  ganglia." 

The  above  condition  constitutes  fibroid  degeneration  of  the 
appendix. 

"C.  When  the  appendix  is  congested  without  the  presence  of 
infection,  as  in  many  cases  of  loose  kidney,  there  may  be  little  or  no 
tenderness  at  the  point  here  described.  There  is  no  tenderness 
at  the  point  of  the  left  lumbar  ganglia." 

The  author  wishes  to  state,  as  before,  that  this  type  of  appen- 
dical congestion  he  believes  not  due  to  loose  kidney,  but  dependent 
on  the  enteroptosis. 

"In  irritations  of  pelvic  origin,  both  right  and  left  lumbar  ganglia 
are  tender.  Take,  for  illustration,  a  case  in  which  the  appendix  and 
the  right  Fallopian  tube  are  bound  together  by  adhesions.  We  are 
to  decide  whether  certain  symptoms  proceed  from  the  appendix  or 
from  the  Fallopian  tube.     If  the  symptoms  proceed  from  the  ap- 

1  Surgical  Section,  New  York  Academy  of  Medicine,  Dec.  5,  1907.  The  author 
here  quotes  Morris'  deductions. 


APPENDICITIS  6oi 

pendix,  the  point  here  described  is  tender  alone.  If  the  symptoms 
proceed  from  the  Fallopian  tube,  both  right  and  left  limibar  ganglia 
are  tender  together. 

"To  recapitulate:  A  patient  comes  in  with  the  appendix  in 
the  form  of  a  question  mark.  Right  lumbar  ganglia  tender  alone 
— appendix  trouble.  Right  and  left  lumbar  ganglia  tender  together 
—pelvic  trouble.  Neither  right  nor  left  lumbar  ganglia  tender — 
trouble  somewhere  cephalad  from  pelvis  and  appendix." 

Blumberg^  describes  a  sign  pointing  to  peritoneal  irritation  or 
inflammation,  which  he  considers  will  be  found  of  assistance  in  the 
diagnosis  of  all  peritoneal  conditions,  and  especially  of  appendicitis. 
It  consists  in  the  fact  that  in  palpating  the  abdomen  in  the  neigh- 
borhood of  an  area  of  inflamed  peritoneum,  not  only  is  the  down- 
ward pressure  painful,  but  if  the  examining  hand  is  suddenly  re- 
moved, the  abrupt  recoil  of  the  abdominal  wall  also  gives  rise  to 
pain.  He  has  found  that  during  an  acute  attack  of  appendicitis 
with  peritoneal  involvement  patients  invariably  state  that  the  pain 
caused  by  the  sudden  removal  of  the  hand  is  greater  than  that  caused 
by  the  pressure,  w^hile  if  the  inflammatory  process  is  subsiding,  the 
two  painful  sensations  first  become  equal  in  intensity,  and  finally 
the  pressure  pain  is  greater  than  the  other.  He  further  believes 
that  the  sign  is  especially  valuable  in  determining  whether  or  not 
operation  is  indicated  in  early  cases,  since  its  presence  indicates 
that  the  peritoneum  has  already  begun  to  take  part  in  the  inflamma- 
tion. Its  sudden  appearance  is,  therefore,  a  danger  signal,  while 
its  gradual  diminution  in  intensity  points  to  a  subsidence  of  the 
peritoneal  reaction.  The  advantage  of  the  method  is  that  it  does  not 
require  an  absolute  estimation  of  the  degree  of  pain  caused  by  the 
palpation,  which  is  often  difficult  to  obtain,  but  demands  simply 
a  comparison  of  the  intensity  of  the  two  painful  stimuli  which  most 
patients  are  able  to  determine  accurately. 

S.  /.  Meltzer's  Method.— Meltzev  extends  the  right  knee,  at  the  same 
time  flexing  the  right  thigh,  while  making  pressure  over  McBurney's 
point.  This  projects  the  psoas  muscle  against  the  appendix  and 
causes  deep-seated  tenderness  in  the  appendix  to  be  more  readily 
appreciated. 

H.  Illoway^  holds  that  forced  flexion  and  especially  forced  ex- 
tension of  the  right  thigh  will  cause  pain  in  the  appendix  if  inflam- 
mation is  present. 

In  many  cases,  especially  in  the  acute  catarrhal  conditions  or  m 
the  most  virulent  gangrenous  type,  no  induration  or  swelling  can  be 
appreciated  on  palpation.  As  I  have  stated,  forcible  palpation  in 
the  endeavor  to  appreciate  the  appendix  should  be  avoided. 

Percussion. — In  cases  with  adhesions,  exudation  without  pus,  or 
of  abscess,  a  boggy  or,  rarely,  fluctuating  mass  can  be  appreciated  in 

1  Miinchener  med.  Wochenschr.,  June  ii,  1907. 

2  Archives  of  Diagnosis,  July,  1908. 


6o2  DisKASES  OF  the;  stomach  and  intestines 

the  right  iHac  fossa,  and  percussion  will  give  a  dull  area  in  the  region 
of  the  cecum.  Fecal  accumulation  as  a  result  of  constipation  must 
be  differentiated  by  the  methods  I  have  already  indicated. 

At  times  great  irritability  of  the  bladder  is  associated  with  this 
condition,  and  the  urine  may  be  scanty  and  contain  indican  and 
albumin,  and  even  acute  nephritis  may  be  present. 

Rectal  and  vaginal  examination  may  sometimes  aid  in  localizing 
the  condition  if  the  appendix  or  abscess  lie  in  the  pelvis.  Inspection 
may  occasionally  show  protrusion  on  the  right  side  or  the  distention 
of  general  peritonitis. 

If  tumor  is  present,  it  may  be  variable  in  size,  more  frequently 
in  the  right  iliac  fossa.  Its  position,  however,  depends  on  that  of 
the  appendix,  as  described  on  page  603. 

Temperature. — An  initial  chill  is  rare.  In  the  acute  cases  fever, 
even  though  slight,  is  present  in  the  early  stages.  It  may  be  only 
99.5°  Fo  or  keep  low,  or  even  rise  to  101°  or  102°  F.,  or  to  a  con- 
siderable height. 

Sometimes  with  circumscribed  abscess  there  may  for  a  time  be 
only  moderate  temperature,  and  some  cases  of  the  virulent  type  will 
suddenly  perforate,  though  the  temperature  be  not  high.  In  both 
of  these,  physical  examination,  the  blood-count,  and  general  symp- 
toms will  aid  the  diagnosis. 

In  general,  a  rise  of  temperature  is  significant  of  an  active  proc- 
ess, even  though  the  temperature  increase  may  be  slight  in  degree 
and  gradual  in  character.  A  sUght  increase  in  rapidity  of  the  pulse 
is  also  suggestive  of  an  acute  process,  and  at  times  this  is  noticeably 
much  out  of  proportion  to  the  temperature,  especially  the  rapid 
pulse  in  gangrene  or  sudden  perforation. 

Gastro-intestinal  Symptoms. — Loss  of  appetite  and  coated 
tongue  are  present.  Emaciation  may  occur  in  cases  of  long  dura- 
tion. 

In  the  severer  cases  vomiting  is  quite  common.  It  may  be  one  of 
the  first  symptoms  occurring  with  the  pain,  and  then  cease,  or  it 
may  continue  for  several  days.  On  the  other  hand,  it  may  come  on 
later  in  the  attack  and  denote  an  exacerbation  of  the  inflammation. 
It  consists  of  the  stomach  contents,  mucus,  and  bile;  and  in  some  cases 
it  may  be  feculent.     Associated  with  it  there  is  at  times  hiccough. 

Black  vomit  ("vomito  negro  appendiculaire ")  is  the  result  of 
toxemia,  producing  hemorrhagic  necrosis  of  the  mucosa  of  the 
stomach  and  hemateme,sis. 

A  few  cases  have  also  been  reported  of  intestinal  hemorrhage 
associated  with  jaundice  and  albuminuria.  These  conditions  are  all 
evidences  of  a  fatal  sepsis.  Acute  ectasia  or  acute  gastro-intestinal 
dilatation  may  also  occur  a  s  complications. 

Bowels. — In  some  cases  the  bowels  are  regular  until  the  attack, 
when  constipation  ensues.  In  others  there  may  be  a  previous  his- 
tory of  constipation.     Diarrhea  of  a  toxemic  type  may  be  one  of 


APPENDICITIS  '  603 

the  initial  symptoms  in  acute  gangrenous  appendicitis.  It  is  probably 
of  septicemic  character.  I  have  noted  it  in  several  such  cases.  In- 
testinal paresis  may  occur  as  a  complication. 

Tumefaction  or  Abscess. — In  cases  of  acute  appendicitis  in  which 
adhesions  are  present,  a  tumor  due  to  adhesions  and  exudation,  or 
an  actual  abscess,  the  position  of  the  mass  is  dependent  upon  the 
position  of  the  appendix  primarily  and  then  upon  the  direction  of  the 
extension  of  the  inflammation  or  burrowing  of  the  pus.  It  may  pass 
down  into  the  pelvis  and  produce  bladder  and  rectal  symptoms,  or 
those  pointing  to  the  tubes  and  ovary  (right) ,  and  be  palpable  through 
the  rectum  and  vagina.  It  may  point  below  Poupart's  ligament  or 
simulate  a  psoas  abscess.  It  may  pass  around  in  front  of  the  cecum 
and  superficial  edema  be  noted  in  this  region,  or  it  may  pass  poste- 
riorly to  the  cecum  and  cause  pain  in  the  flank  or  back,  with  swell- 
ing, and  produce  perinephritic  abscess  or  lumbar  abscess.  It  may 
pass  inward  to  the  left  and  produce  obstruction  through  pressure  or 
bands.  It  may  pass  upward  and  produce  subphrenic  abscess  and 
even  perforate  the  diaphragm,  pleura,  and  lungs.  It  may  develop  in 
a  hernial  sac. 

At  times  the  tumor  appears  at  the  lower  border  of  the  liver,  when 
the  tip  of  the  appendix  lies  in  this  region.  The  condition  must  then 
be  differentiated  between  retroverted  appendical  abscess  and  gall- 
bladder or  renal  inflammation,  such  as  infarction. 

Brewer  has  shown  that  tenderness  at  the  costovertebral  angle  is  diag- 
nostic of  the  latter ;  the  urine  analysis  is  also  important,  and  especially 
differential  analysis  after  catheterization  of  both  ureters.  The  his- 
tory will  usually  point  to  appendicular  inflammation  or  disease  of  the 
gall-bladder,  but  operative  procedure  will  alone  settle  some  cases. 

The  value  of  Head's  zones  of  cutaneous  hyperalgesia  as  an  aid 
to  differential  diagnosis  will  be  referred  to  under  that  section. 

The  elements  in  the  diagnosis  of  abscess  formation  are  the  grad- 
ual increase  of  the  local  tumor  and  the  aggravation  of  the  general 
symptoms.  The  abscess  may  perforate  and  cause  a  general  peri- 
tonitis or  the  inflammation  may  extend  to  the  peritoneum  without 
perforation,  so  that  there  may  be  a  slower  process  with  various  sac- 
culated collections  of  pus. 

The  abscess  may  rupture  through  the  skin  or  empty  into  the 
cecum,  colon,  small  intestine,  bladder,  rectum,  or  pelvis  of  the  kidney. 

Fukninating  Type  of  Acute  Appendicitis. — This  is  the  most 
dangerous  and  fatal  of  all.  This  type  of  appendicitis  can  be  sub- 
divided into  two  clinical  varieties.  Both,  are  characterized  by  the 
rapidity  of  the  pathologic  changes  in  the  appendix  and  by  the  ab- 
sence of  protective  peritoneal  adhesions,  so  that  general  peritoneal 
infection  occurs  quite  rapidly. 

In  the  first  class  the  pain  in  the  region  of  the  appendix  and  some 
of  the  subjective  and  objective  symptoms  are  acute  and  quite 
marked,  but  not  all  of  them. 


604  DISEASES    OE   THE    STOMACH   AND   INTESTINES 

In  the  second  class,  and  by  far  the  most  dangerous  because  fre- 
quently undiagnosed  until  the  general  infection  has  occurred,  the 
patient  complains  of  no  marked  subjective  symptoms;  in  fact,  may 
say  he  is  quite  comfortable,  and  the  objective  symptoms  are  not 
marked.  There  are  peculiarities  in  the  pulse,  temperature,  and 
especially  in  the  blood  changes  which  tell  the  story. 

Acute  gangrene  of  the  appendix,  with  or  without  perforation,  is 
the  pathologic  condition  generally  found  on  operation;  though  I 
have  also  seen  an  acute  diffuse  or  purulent  inflammation  of  the 
appendix,  either  with  perforation  or  without  it,  produce  the  condi- 
tion. In  some  cases  perforation  was  apparently  due  to  ulceration 
from  a  fecal  concretion  which  was  found  in  the  cavity.  Perforation 
undoubtedly  is  present  in  many  cases,  but  I  agree  with  Riegel  that 
acute  virulent  infection  of  the  peritoneum,  commencing  in  the  region 
of  the  appendix,  will  produce  the  same  clinical  symptoms. 

In  the  first  class  of  cases  the  patient  may  have  given  a  history  of 
previous  attacks  or  have  had  some  indefinite  abdominal  symptoms 
for  several  days,  or  may  be  attacked  without  warning,  as  in  the  mid- 
dle of  the  night,  with  severe  pain  in  the  abdomen.  It  may  not  at 
first  be  referred  to  the  appendical  region,  may  be  epigastric  or  umbil- 
ical pain,  but  gradually  localizes  there.  There  is  no  tumor,  the 
muscles  are  rigid,  the  appendix  tender.  The  abdomen  rapidly  dis- 
tends. The  patient  is  anxious  and  looks  sick.  The  temperature  at 
first  may  not  be  elevated  much.  The  pulse  is  rapid  and  out  of  proportion 
to  the  temperature.  General  symptoms  of  peritonitis  rapidly  ensue. 
In  others  the  pulse  may  be  slow  at  first  and  a  low  temperature  with 
local  signs  of  appendicitis,  but  acute  history,  nausea,  vomiting,  and 
marked  constipation.  The  pulse  later  becomes  more  rapid,  high 
temperature,  distention,  coated  tongue,  and  general  tenderness. 

In  others  the  first  symptoms  are  of  collapse,  with  subnormal 
temperature,  rapid  pulse,  cold  and  clammy  skin,  respiration  increased 
in  frequency,  followed  by  symptoms  of  general  peritonitis. 

In  the  second  class  of  cases  the  condition  may  be  very  deceptive. 
The  patient,  in  perfect  health,  may  suddenly  complain  of  general 
abdominal  pains.  I  have  seen  a  number  with  diarrhea  of  toxic 
character  as  the  initial  symptom.  The  patient  may  impute  the 
symptoms  to  dietary  indiscretions.  The  tenderness  may  be  diffuse 
or  equal  on  both  sides,  and  gradually  it  localizes  in  the  appendix 
region.  Even  so,  the  tenderness  at  McBurn.ey's  point  may  not  be 
very  acute,  and  the  rigidity  of  the  right  rectus  not  very  marked  or 
very  slight.  The  patient  may  state  that  he  feels  quite  comfortable. 
The  temperature  may  be  moderate  (ioo°  F.)  and  the  pulse  loo. 

The  temperature  tends  to  gradually  creep  up,  the  pidse  to  increase 
in  rapidity  out  of  proportion  to  the  temperature  increase,  which  last 
may  be  slight,  and  the  character  of  the  pulse  changes;  the  patient  looks 
more  sick,  but  still  complains  of  no  special  symptoms  except  slight 
pain  or  exacerbations  of  it  in  the  right  side,  and  still  feels  comfortable. 


APPENDICITIS 


6o.S 


The  blood  examination  shows  in  many  cases  moderate  leuko- 
cytosis (14,000  to  16,000),  but  marked  increase  in  the  polynuclears 
(88  to  92  per  cent.)-  Hyperinosis  is  present.  The  patient  presents  as 
yet  no  symptoms  of  general  peritonitis,  but  nevertheless  the  sepsis  is 
marked  in  these  cases,  and  unless  immediate  operation  is  performed 
will  have  a  virulent  type  of  septic  peritonitis. 

A  patient  of  mine  recently  operated  on  by  Hartley  presented  the 
mild  type  of  symptoms  just  described:  Diarrhea  at  4  p.  M.;  no  ap- 
pendical  pain  or  tenderness;  localized  appendical  pain  at  midnight, 
when  the  surgeon  was  at  once  called  in.  Differential  blood-count  at 
8  A.  M.  and  i  p.  m.,  showing  a  gradual  increase  in  polynuclears  and 
low  leukocytosis  (15,000  to  16,000).  The  patient  was  quite  com- 
fortable; no  distention;  slight  pain  over  appendix,  but  the  tempera- 
ture and  pulse  slowly  creeping  up. 

At  5  P.M.  operation  at  the  New 
York  Hospital ;  acute  gangrene  of  ap- 
pendix and  commencing  peritonitis; 
ultimate  recovery. 

The  examination  of  the  blood  is 
thus  imperative  when  possible. 

The  Blood  in  Acute  Appendi- 
citis.— Hyperinosis  (increased  fibrin 
in  the  blood)  has  been  demonstrated 
by  E.  E.  Smith  and  Bartlett^  to  be 
more  marked  in  direct  proportion  to 
the  involvement  of  the  serous  surface, 
and  hence,  depending  on  its  degree,  is 
suggestive  of  proportional  peritonitic 
infection. 

One  of  the  most  important  factors 
in  the  determination  as  to  operative 
procedure  in  appendicitis  and  as  to 
the  relative  severity  of  the  case  is  the 
differential  leukocyte  count.  Charles 
Langdon  Gibson  has  especially  pointed 
out  that  it  is  the  disproportion  between  the  percentage  of  poly- 
nuclear  cells  and  the  total   leukocytosis  that  is  important. 

The  chart  (Fig.  221)  assumes  that  10,000  leukocytes  per  cubic 
millimeter  is  the  upper  limit  of  ordinary  normal  leukocytosis,  and 
that  75  is  the  normal  percentage  of  polynuclears.  Gibson  further 
assumed  that  in  inflammations  which  are  well  resisted  the  poly- 
nuclear  cells  are  increased  approximately  by  i  per  cent,  for  every 
1000  leukocytes  above  the  normal  10,000  per  cubic  millimeter. 
Then  in  the  chart  the  horizontal  line  will  indicate  a  leukocyte  count  of 
1 1 ,000  with  76  per  cent,  of  polynuclears,  whereas  the  rising  line  repre- 
sents a  leukocytosis  of  1 1 ,000,  but  with  86  per  cent,  of  polynuclears. 
I  Blood  Reactions  of  Inflammation,  Med.  Record,  Feb.  8.  1908. 


Fig.  221. — C.  L.  Gibson's  differen- 
tial chart  for  leukocytosis. 


6o6  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

If  the  line  connecting  the  total  leukocytes  and  the  percentage  of 
polynuclears  runs  fairly  horizontal,  it  indicates  a  lesion  that,  whether 
severe  or  not,  is  well  borne  and,  therefore,  of  good  prognosis. 

If  the  line  runs  upward  from  the  leukocyte  to  the  polynuclear  side, 
it  indicates  a  rather  severe  lesion  and  less  resistance. 

Fatal  cases  all  have  a  rising  line. 

A  falling  line  {e.  g.,  leukocytosis  of  30,000  with  80  per  cent,  of 
polynuclears)  means  a  mild  lesion;  in  appendicitis  it  would  probably 
indicate  an  abscess  well  shut  off,  with  little  febrile  or  constitutional 
disturbance. 

Gibson's  conclusions  are  as  follows :  The  differential  blood-count 
and  its  relation  to  the  total  leukoc\i:osis  is  the  most  valuable  diagnos- 
tic and  prognostic  aid  in  acute  surgical  diseases  that  is  furnished  by 
any  of  the  methods  of  blood  examination. 

It  is  of  chief  value  in  indicating  fairly  consistently  the  existence  of 
suppuration  or  gangrene,  as  evidenced  by  an  increase  of  the  poly- 
nuclear cells  disproportionately  high  as  compared  to  the  total  leu- 
kocytosis. 

E.  B.  Smith^  shows  that  it  is  an  indicator  of  the  activity  of  the 
process  and  not  invariably  of  gangrene;  but  if  the  absolute  leuko- 
cytosis is  low  (below  15,000),  with  high  polynuclears,  it  is  probably 
gangrene. 

Gibson  further  holds  that  the  greater  the  disproportion  the  surer 
are  the  findings,  and  in  extreme  disproportions  the  method  has  proved 
itself  practically  infallible. 

As  the  relative  disproportion  between  the  leukocytosis  and  the 
percentage  of  the  polynuclear  cells  is  of  so  much  more  value  than  the 
findings  based  on  a  leukocyte  count  alone,  this  latter  method  should 
be  abandoned  in  favor  of  the  newer  and  more  reliable  procedure. 

The  negative  findings,  showing  no  relative  increase  or  even  an 
actual  decrease  of  the  proportion  of  the  polynuclears  cells,  while  of 
less  value,  show  with  rare  exceptions  the  absence  of  the  severer  forms 
of  inflammation. 

In  its  practical  applications  the  method  is  of  more  frequent  value 
in  the  interpretation  of  the  severity  of  the  lesions  of  appendicitis  and 
their  sequelae. 

Though  N.  E.  Ditman,  in  a  paper  read  before  the  Obstetrical 
Section  of  the  Academy,  November,  1906,  criticizes  the  differential 
count  as  of  doubtful  value,  Sondern-  shows  that  in  cases  quoted  the 
pus  was  encapsulated  in  such  a  way  that  no  toxic  absorption  occurred, 
and  also  demonstrates  that  polynuclear  increase  may  occur  in  other 
than  suppurative  conditions. 

It  is  a  well-known  fact  that  such  encapsulated  abscesses  may  occur 
without  marked  constitutional  symptoms,  but  physical  signs  determine 
their  presence. 

1  Blood  Reactions  of  Inflammation,  Medical  Record,  Feb.  8,  1908. 

2  New  York  Medical  Journal,  June  26,  1907. 


APPENDICITIS  607 

In  this  type  the  processes  are  less  active,  and  this  is  probably  the 
chief  cause- 

I  have  seen  a  very  low  leukocytosis  with  a  general  fatal  peritonitis, 
the  system  evidently  being  overwhelmed  by  the  poison.  The  physical 
signs,  with  increased  polynuclears  and  hyperinosis,  aid  our  diagnosis 
in  exceptional  cases. 

A  low  leukocytosis  with  high  polynuclear  count  also  shows  poor 
resisting  power  to  the  infection. 

To  recapitulate :  We  may  have  numerous  types  of  acute  appendi- 
citis, which  clinically  are  as  follows : 

1.  Simple  catarrhal  appendicitis  with  mild  symptoms,  lasting 
a  few  days  to  a  week  or  ten  days;  often  secondary  to  colitis,  intes- 
tinal disturbances,  or  fecal  impaction  in  the  caput  coli;  blood  changes 
are  moderate  and  the  attack  soon  subsides  under  medical  treatment 
combined  with  the  ice-bag.     It  may  never  recur. 

2.  Acute  appendicitis  (diffuse),  symptoms  more  severe;  may  be 
adhesions  or  slight  exudation;  temperature  higher;  more  marked 
tenderness;  tumor  often  palpable,  but  may  disappear.  It  may 
become  chronic  or  recurrent. 

3.  Acute  appendicitis,  with  abscess,  chills,  tumor,  etc.,  present- 
Abscess  may  perforate. 

4.  Fulminating  type,  perforation  or  gangrene. 

Remote  Effects  of  Acute  Appendicitis. — They  are  as  follows: 
Hemorrhage  from  perforation  of  a  blood-vessel;  suppurative  pyle- 
phlebitis; thrombosis  of  the  iliac  or  femoral  veins;  pulmonary  em- 
bolism ;  strangulation  of  the  bowel ;  subsequent  symptoms  may  occur 
due  to  incomplete  removal  or  subsequent  adhesions.  Hartley  has 
noted  intestinal  paresis  in  mild  cases,  with  s3nTiptoms  of  ileus  re- 
sulting; also  infection  of  the  mesenteric  glands,  subsiding  in  some 
cases  after  appendectomy,  and  in  others  causing  subsequent  in- 
flammation. 

Chronic  Appendicitis. — ^This  may  follow  an  ordinary  acute 
attack  or  be  chronic  from  its  incipiency- 

The  latter  often  is  secondary  to  chronic  intestinal  catarrh.  The 
patient  has  frequently  a  continuous  feeling  of  discomfort  in  the  ap- 
pendical  region;  slight  tenderness  on  pressure;  generally  intestinal 
and  frequently  nervous  disturbances  associated,  also  constipation  or 
gastric  disturbances.  SUght  tenderness  or  discomfort  on  pressure 
at  McBurney's  point-  This  may  disappear  for  periods-  At  times 
no  tenderness  can  be  elicited  at  McBurney's  point,  but  is  noted  at 
Morris'  point.     There  may  be  exacerbations  of  acute  attacks. 

Indiscretions  in  diet  often  cause  exacerbations  of  the  symptoms- 
In  some  of  these  cases  there  is  simply  a  chronic  catarrhal  condition, 
but  more  frequently  angulation  with  adhesions. 

This  is  the  type  where  palpation  by  Edebohl's  method  is  safe  and 
of  value,  and  where  at  times  the  enlarged  appendix  can  be  appre- 
ciated. 


6o8  DISEASES    OF    THE    STOMACH    AXD    IXTESTIXES 

The  patient  lies  on  his  back^  with  the  thighs  flexed,  and  the  ex- 
aminer, placing  three  or  four  fingers  of  the  right  hand,  palm  side 
downward,  draws  them  over  the  abdomen  from  the  umbilicus  to  the 
anterior  superior  spine  of  the  ileum,  exerting  considerable  pressure. 
The  appendix  can  be  recognized  as  a  firm  cord.  Morris  reinforces 
this  hand  with  the  three  fingers  of  the  left  hand. 

In  the  chronic  cases  there  is  generally  no  temperature  unless 
subacute  or  acute  exacerbations  occur. 

Harmful  Involution  of  the  Appendix. — Symptoms  of  harmful 
involution  of  the  appendix  (Morris) : 

I.  Symptoms  of  auto-intoxication  with  attacks  of  headache,  ner- 
vousness, poor  appetite,  etc.  2.  Intestinal  dyspepsia.  3.  Discom- 
fort in  the  appendical  region.  4.  An  appendix  feeling  hard  and 
narrow  on  palpation.     5.  Hyperesthesia  of  the  right  lumbar  plexus. 

There  is  persistent  distention  of  the  cecum  and  ascending  colon, 
with  gas  and  a  sensation  of  discomfort  in  the  appendical  region. 
The  patient  has  a  tendency  to  press  upon  the  abdomen  at  that  point 
or  to  lean  against  a  table.  The  sensation  may  pass  away  for  a  few 
hours  or  days,  but  tends  to  recur  and  last  for  years. 

On  palpation  the  involution  appendix  feels  narrow  and  hard. 
There  is  no  history  of  acute  or  chronic  appendicitis.  The  type  gen- 
erallv  occurs  in  those  over  twenty-five  or  thirty  years  of  age. 

Diagnosis  and  Differential  Diagnosis. — Abdominal  pain,  be- 
coming localized  in  the  right  iliac  fossa;  tenderness  at  McBurney's 
point ;  rigidity  of  the  right  rectus ;  temperature ;  rapid  pulse ;  gastro- 
intestinal disturbances;  in  some  cases  the  presence  of  tumefaction 
and  in  others  the  subsequent  development  of  peritonitis— are  all 
diagnostic  of  appendicitis. 

In  addition  there  are  the  differential  leukoc^-te  count  and  hyperi- 
nosis,  which  are  an  aid  to  diagnosis. 

Renal  colic  with  calculus  impacted  in  the  right  ureter  may 
simulate  appendicitis,  but  there  is  the  history  of  acute  pain  in  the 
kidney,  burning  sensation  of  the  urine,  and  drawing  up  of  the  right 
testicle,  with  sand,  gravel,  or  blood,  etc.,  in  the  urine. 

With  Dietls'  crisis  there  is  the  movable  kidney,  the  history  of 
the  attack,  and  the  kidney  is  swollen  and  sensitive. 

In  intestinal  colic  the  pain  is  relieved  after  passage  of  flatus. 

In  biliary  coUc  the  pain  radiates  to  the  back  and  up  to  the  right 
shoulder,  usually  with  a  previous  history  of  gall-stones,  etc. 

In  perforation  of  the  gall-bladder  or  duodenum  the  contents  gravi- 
tate toward  the  appendix ;  and  this  possibility  must  always  be  consid- 
ered in  apparently  acute  perforative  appendicitis.  In  these  cases  the 
sudden  acute  pain  occurs  in  the  epigastrium  and  right  hypochondrium. 

In  women  the  differential  diagnosis  between  a  low  appendix  and 
salpangitis  is  sometimes  difficult,  as  they  frequently  are  associated. 

1  It  has  been  at  times  recommended  to  examine  with  the  patient  standing 
erect  or  bending  slightly  forward,  but  the  dorsal  posture  is  preferable. 


APPENDICITIS  609 

With  pneumonia,  especially  central  near  the  right  base,  and  with 
diaphragmatic  pleurisy  there  is,  occasionally  in  the  early  stages, 
pain  transferred  to  the  right  iliac  fossa  and  mistaken  for  appendicitis. 
The  physical  examination  of  the  lungs  and  pulmonary  symptoms 
should  be  carefully  obser\^ed.^     This  possibility  must  be  considered. 

In  typhoid  fever  there  may  be  pain  in  the  right  iliac  fossa  and 
appendicitis  is  often  a  complication. 

In  simple  typhoid  there  is  no  leukocytosis,  but  leukopenia. 

In  typhoid  with  appendicitis,  in  addition  to  the  right  iliac  pain 
and  tenderness,  the  presence  of  leukocytosis,  increased  polynuclears, 
and  hyperinosis  make  the  diagnosis  of  appendicitis. 

As  an  aid  to  differential  diagnosis  in  affections  of  the  viscera, 
the  determination  of  Head's  zones  (cutaneous  hyperalgesia)  is  of 
value.  This  is  especially  true,  I  believe,  in  the  differentiation  of 
appendicitis  from  the  conditions  to  which  I  have  just  referred. 
Head  found  that  in  many  visceral  affections,  if  the  sensitiveness  of 
the  skin  was  tested  by  running  a  pin  point  over  the  cutaneous  sur- 
face, there  could  be  shown  to  exist  areas  over  w^hich  there  w^as  a 
more  or  less  hypersensitiveness  to  pain.  These  areas  w^ere  constant 
and  distinct,  could  be  mapped  out  on  the  surface  of  the  skin,  and, 
when  present,  were  almost  an  infallible  sign  of  an  affection  of  the 
organ  to  which  they  corresponded.  The  skin  tenderness  was  super- 
ficial and  extended  over  definite  areas  which  never  overlapped  one 
another.  Each  area  or  zone  of  hyperalgesia  had  a  "maximum  re- 
gion" which  often  corresponded  to  the  seat  of  pain.  These  areas 
were  sensitive  to  heat  and  cold,  but  not  to  simple  touch. 

The  areas  corresponded  to  segments  of  the  spinal  cord,  not  to  the 
distribution  of  peripheral  nerves  or  spinal  nerve-roots.  The  zones 
v/ere  named  according  to  the  segments  of  the  cord :  cer\4cal,  i  to  7 ; 
dorsal,  i  to  12;  lumbar,  i  to  5;  sacral,  i  to  4.  They  were  broader 
in  front  at  the  median  line,  narrowed  at  the  side  of  the  body,  and 
again  broaden  out  near  the  spinal  column.  The  zones,  as  a  rule, 
never  extend  bevond  the  median  line  in  front  or  behind.  Head 
gives  the  following  zones  for  the  abdominal  viscera : 

Stomach,  sixth,  seventh,  eighth,  and  ninth  dorsal.  Cardiac  end, 
sixth  and  seventh  dorsal,  right.  Pyloric  end,  eighth  and  ninth 
dorsal,  left. 

Liver,  eighth,  ninth,  and  tenth  dorsal,  right. 

Gall-bladder,  eighth  and  ninth  dorsal,  right. 

Intestines,  ninth,  tenth,  eleventh,  and  twelfth  dorsal. 

Colon,  ninth,  tenth,  and  eleventh  dorsal. 

Cecum  and  appendix  vermiformis,  tenth  and  eleventh  dorsal,  right- 
Kidney,  tenth  dorsal,  sometimes  eleventh  dorsal. 

1  Determination  of  Head's  zones  is  of  value;  the  zone  for  the  lungs  is  from 
first  to  the  ninth  dorsal  segment,  chiefly  the  third,  fourth,  and  fifth,  which  give 
hyperalgesia  over  the  thorax.     With  appendicitis  hyperalgesia  is  below  the  um- 
bilicus (page  614). 
39 


6lO  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Ureter,  eleventh  and  twelfth  dorsal,  first  lumbar. 

Bladder  (first?),  second,  third,  and  fourth  sacral. 

Uterus,  tenth,  eleventh,  and  twelfth  dorsal,  first  lumbar. 

Appendages,  eleventh  and  twelfth  dorsal,  first  lumbar. 

Head  first  tested  sensitiveness  to  pain  by  pinching  up  folds  of 
skin  and  later  by  stroking  the  skin  with  the  point  of  a  sharp  pin. 
Elsberg^  and  Neuhof  suggest  the  following  method  of  examination : 

"A  sharp  pin  is  held  between  the  thumb  and  index-finger  of  the 
right  hand,  the  nail  of  the  index-finger  resting  on  the  patient's  skin. 
The  pin  is  then  made  to  traverse  slowly  the  surface  of  the  skin, 
care  being  taken  that  the  nail  of  the  index-finger  presses  equally 
along  the  area  examined.  The  patient  is  instructed  to  say  '  now '  as 
soon  as  the  pin  stroke  becomes  painful. 

"  In  examining  the  skin  of  the  abdomen  f or  hyperalgesic  areas,  the 
pin  traverses  the  abdomen  from  side  to  side  and  from  above  down- 
ward ;  the  points  at  which  the  patient  complains  of  pain  are  marked. 
In  this  manner  it  is  possible  to  map  out  areas  on  the  skin,  and  when 
such  an  area  has  been  found,  the  pin  is  made  to  approach  it  from 
all  sides,  so  that  its  form  and  position  can  be  determined.  Care 
must  be  taken  that  the  pressure  of  the  pin  point  remains  constantly 
the  same,  especially  as  the  pin  passes  over  the  groin  and  slips  off  the 
costal  border  or  over  the  crest  of  the  ileum. 

"After  the  zone  has  been  thus  mapped  out  on  the  skin  the  pro- 
cedure is  repeated  a  second  time,  and  now  it  is  a  good  plan  for  the 
operator  to  control  both  patient  and  himself  by  keeping  both  the 
patient's  and  his  own  eyes  away  from  the  pin. 

"The  hyperalgesia  is  sometimes  so  marked  that  the  patient  will 
shrink  or  cry  out  as  soon  as  the  border  of  the  zone  is  reached.  In 
very  young  children  the  examination  is  useless,  but  older  children 
will  give  correct  answers. 

"  If  the  examination  is  carried  out  in  the  manner  above  described 
it  will  be  possible  in  a  large  number  of  patients  with  visceral  affec- 
tions to  map  out  areas  of  hyperalgesia  extending  from  the  median 
line  in  front  to  the  spines  behind.  The  '  maximum '  areas  can  often 
be  mapped  out  lying  within  the  boundaries  of  the  zones ;  sometimes 
onlv  the  '  maxima '  are  present.  Sometimes  several  '  maxima '  are 
found  in  one  zone." 

The  zones  appear  early  in  the  course  of  visceral  affections,  and 
frequently  persist  throughout.  They  have  been  reported  as  appear- 
ing very  early;  for  example,  in  the  commencement  of  acute  appendi- 
citis while  the  pain  was  still  in  the  epigastric  region  and  there  was  no 
local  tenderness  at  McBurney's  point,  the  zone  for  the  appendix  was 
discovered.  Shortly  after  the  typic  symptoms  appeared.  One  must 
remember  the  following  (Elsberg) : 

I.  The  characteristic  zone  may  appear  after  palpation  of  the  dis- 
eased organ. 

1  American  Journal  of  the  Medical  Sciences,  Nov.,  1908. 


APPENDICITIS  6ll 

2.  The  hyperalgesia  zone  will  not  appear  on  examination  until 
fifteen  to  thirty  minutes  have  elapsed  after  removal  of  the  ice-bag  or 
hot-water  bag,  if  such  have  been  applied. 

3.  The  disappearance  of  the  zone,  as  a  rule,  follows  relief  of  the 
lesion  of  the  affected  viscus. 

4.  The  zones  may  disappear  temporarily  after  repeated  examina- 
tions in  close  succession.     Later  they  reappear. 

5.  The  disappearance  of  the  zone,  together  with  persisting  or  in- 
creasing symptoms,  is  probably  a  sign  of  ill  omen. 

6.  The  zones  are  not  invariably  present.  While  the  absence  of  a 
characteristic  zone  in  a  suspected  affection  of  an  abdominal  organ 
does  not  mean  that  there  may  not  be  disease  of  that  organ,  the  pres- 
ence of  the  zone  means  that  there  is  an  undoubted  lesion.  From  this 
one  must  not  conclude  that  the  viscus  which  gives  the  zone  is  the 
one  which  causes  all  the  symptoms,  for  we  may  get  a  zone  from  an 
organ  which  is  secondarily  affected. 

7.  The  presence  of  areas  of  skin  hyperalgesia  corresponding  to 
several  viscera  may  mean  a  combined  lesion  of  several  adjoining  vis- 
cera, although  it  may  occasionally  mean  disease  of  the  spinal  cord 
itself. 

8.  The  presence  of  a  Head  zone  alone  must  not  be  the  only  fac- 
tor in  arriving  at  a  diagnosis,  but  it  must  be  used  in  conjunction 
with  other  signs  and  symptoms.  When  one  is  in  doubt  as  to  which  of 
several  viscera  is  the  seat  of  the  lesion,  the  presence  of  the  charac- 
teristic zone  has  been  an  aid ;  for  example,  in  differential  diagnosis 
between  appendicitis  (with  retroverted  appendix)  and  kidney  and 
gall-bladder  disease,  or  between  appendicitis  and  salpingitis.  It 
seems  preferable  to  adopt  Elsberg's  method  and  speak  of  the  zones 
by  the  names  of  the  viscera  to  which  they  belong.  The  position 
of  his  zones  vary  a  trifle  from  Head's,  and  are  as  follows: 

Thus,  the  stomach  zone  corresponds  to  the  seventh,  eighth,  and 
ninth  segments  of  Head  (according  to  Head,  sixth,  seventh,  eighth, 
and  ninth) ;  the  gall-bladder  zone,  to  the  eighth  and  ninth  segments 
on  the  right  side  (same  as  Head's  diagrams) ;  the  appendix  zone,  to 
the  tenth  and  eleventh  segments  of  Head  on  the  right  side.  It  will  be 
found,  in  the  description  of  the  zones,  that  the  Umit  of  the  posterior 
portions  is  not  absolute.  Thus,  in  describing  the  gastric  zone,  that 
it  extends  from  the  sixth  to  the  tenth  vertebrae  approximately. 
The  zones,  except  the  gastric  zone,  stop  sharply  at  the  posterior 
median  line,  but  their  upper  and  lower  margins  are  more  variable. 

The  zone  appears  on  that  side  of  the  body  on  which  the  affected 
organ  has  its  nervous  connections,  the  side  on  which  the  organ  is 
normally  situated.  If  an  organ  belongs  on  the  left  side,  the  hyper- 
algesic  zone  will  be  found  on  that  side,  even  if  the  organ,  through 
disease  or  mobility,  lies  on  the  other  side  of  the  body. 

Those  areas  are  called  "  objective  zones  "  when  the  patient  suf- 
fers actual  pain  as  the  stroking  pin  enters  them.     All   less  painful 


6l2 


DISEASES    OF   THE   STOMACH   AND   INTESTINES 


zones  will  be  called  "subjective  zones."  By  an  "anterior  zone"  we 
mean  an  anterior  maximal  area;  by  a  "posterior  zone,"  a  posterior 
maximal  area. 

The  Stomach. — The  complete  gastric  zone  was  found  to  be  un- 
common. It  extended  as  a  broad  belt  all  around  the  body.  At 
times  only  a  portion  of  it  showed  on  examination. 

In  the  median  line  in  front  it  extends  from  the  xiphoid  almost 
to  the  navel ;  it  then  passes  upward  and  backward  on  both  sides  to- 
ward the  spine,  where  it  extends  from  the  sixth  to  the  tenth  verte- 


Gall  Bladder 


Cecum  and 
Appendix 

Ovary  and  Tube 


^]  Stomach 
(Left  Half) 


Kidney 


Ureter 


Fig.  222,  a. — Head's  zones.  The  general  location  and  outline  of  the  zones 
of  cutaneous  hyperalgesia  for  some  of  the  abdominal  viscera.  Anterior  view. 
The  maxima  are  deeply  shaded.  Only  the  left  half  of  the  gastric  zone  is  given. 
The  ureteral  zone  consists  of  a  series  of  maxima  (diagrammatic)  (Elsberg  and 
Neuhof). 

bra  (approximately).  Incomplete  zones  are  more  frequent,  either 
an  anterior  portion  extending  to  the  right  or  to  the  left,  or  on  both 
sides  of  the  anterior  median  line. 

In  Fig.  222,  a  and  h,  the  various  zones  are  depicted  on  the  ante- 
rior and  posterior  surfaces  of  the  body. 

The  Duodenum. — The  duodenal  zone  lies  between  the  gall-blad- 
ber  and  the  appendix  zones.  It  lies  almost  completely  to  the 
right,  but  occasionally  extends  slightly  to  the  left  of  the  anterior 
median  line.     Anteriorly  it  is  broad ;  its  upper  Hmit  is  about  on  a 


APPENDICITIS 


613 


horizontal  line  midway  between  the  umbilicus  and  the  ensiform  car- 
tilage; its  lower  border  is  a  little  below  the  umbilicus.  It  extends 
backward  and  slightly  upward,  and  narrows;  at  the  anterior  axillary 
Hne  it  is  very  narrow^  (about  i  J  inches) ;  it  then  becomes  broader, 
and  is  lost  about  the  midscapular  line.  It  corresponded  roughlv  to 
the  ninth  dorsal  zone  of  Head. 

With  a  perforating  duodenal  ulcer,  intestinal  contents  gravitate 
to  the  appendical  region.  If  the  ulcer  was  occult,  differential  diag- 
nosis from  appendicitis  may  be  difficult.  Presence  of  the  typic 
zone  may  prove  of  assistance. 


10th  Dorsal  Spine 


Isi  Sacral 


Fig.  222,  b. — Head's  zones.     The  general  location  and  outline  of  the  posterior 
parts  of  the  zones  (diagrammatic)  (Elsberg  and  Xeuhof). 


Gall-bladder  and  Liver. — This  zone  is  present  in  acute  affections 
of  the  gall-bladder  more  often  than  in  any  other  acute  intra-abdomi- 
nal affection.  In  these  cases  the  Head  zone  has  often  been  a  val- 
uable diagnostic  aid.  In  many  cases  an  enlarged,  tender,  and 
palpable  gall-bladder  makes  the  diagnosis  easy,  but  the  recognition 
of  the  disease  is  often  difficult  or  impossible  in  stout  patients  with- 
out jaundice,  with  marked  abdominal  distention  and  rigidity.  These 
patients  may  refer  their  pain  to  the  right  lower  abdomen,  and  may 
have  their  tenderness  in  this  region.  Acute  intestinal  obstruction, 
acute  pancreatitis,  or  acute  appendicitis  are  diagnoses  often  made. 


6l4  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

In  some  patients  the  presence  of  a  zone  of  hyperalgesia  has  been 
the  only  localizing  sign. 

The  gall-bladder  zone  lies  in  the  right  half  of  the  abdomen,  above 
the  level  of  the  umbilicus.  The  complete  zone  starts  exactly  at  the 
median  line  in  front,  extending  from  some  distance  below  the 
xiphoid  to  a  short  distance  above  the  navel.  Tracing  it  backward, 
it  slants  obliquely  upward  and  becomes  narrow,  passing  partly  over 
and  partly  below  the  costal  arch.  It  is  narrowest  at  the  midaxillary 
line,  where  it  is  about  2  inches  wide.  Posteriorly  it  becomes 
broader,  and  at  the  spines  it  is  about  as  wide  as  in  front.  In  some 
cases  more  or  less  of  the  anterior  portion  only  has  been  present 
(maximal  area). 

Kidney  and  Ureter. — -The  kidney  zone  is  wide  at  the  posterior 
median  line,  where  it  begins,  and  gradually  narrows  anteriorly.  Its 
greatest  breadth  is  at  the  spinal  column.  It  narrows  to  make  a  tri- 
angular area,  with  a  rounded  apex,  situated  a  little  to  that  side  of 
the  anterior  median  line  on  which  the  zone  lies.  It  never  quite 
reaches  the  anterior  median  line.  Each  zone  is  strictly  limited  to 
its  half  of  the  body.  There  is  no  difference  in  contour  between  the 
right  and  left  kidney  zones.  The  kidney  zones  are  complicated  b)^ 
the  additional  ureteral  zones  that  are  present  in  certain  cases.  The 
ureteral  zone  springs,  so  to  speak,  from  the  lower  margin  of  the 
kidney  zone  at  the  anterior  axillary  line.  In  an  average  adult  it  is 
about  3  inches  wide  at  its  beginning.  It  narrows  in  its  down- 
ward course,  and  passing  obliquely  downward  and  forward,  it  termiv 
nates  on  its  side  of  the  penis  and  scrotum  in  the  male ;  the  labia  in 
the  female.  After  the  first  narrowing  it  widens  again  well  below 
the  umbilical  level.  In  the  male,  it  can  be  ascertained  that  the  zone 
spreads  fan  shape  to  the  anterior  median  line  over  the  pubic  area 
and  its  half  of  the  scrotal  and  penile  skin.  There  are  anterior  and 
posterior  kidney  maximal  areas.  The  ureteral  zone  seems  to  be 
made  up  of  a  series  of  maxima.  The  kidney  and  ureteral  zone  is 
most  often  present,  as  in  the  other  intra-abdominal  affections,  in  the 
presence  of  pain  and  tenderness. 

In  the  differential  diagnosis  of  septic  infarction  of  the  kidney, 
pyelonephritis,  etc.,  from  retroverted  appendix  (appendicitis),  deter- 
mination of  the  kidney  zone  is  of  value,  taken  in  connection  with 
Brewer's  sign,  urinary  analysis,  etc.  (author). 

Vermiform  Appendix. — The  zone  begins  at  the  median  line  in 
front,  sometimes  a  little  to  its  left,  from  a  point  a  short  distance 
below  the  umbilicus  to  one  equally  distant  from  the  symphysis 
pubis.  It  narrows  toward  the  anterior  axillary  line  to  a  width  of 
about  2  inches  (average  adult).  From  this  line  it  widens  and 
spreads  to  the  posterior  median  line  from  the  eleventh  dorsal  to  the 
second  lumbar  spines  (approximately).  At  the  anterior  median 
line  there  is  often  a  tongue-like  downward  extension  of  the  zone 
(Fig.  222,  a  and  b).     There  is   an   anterior  maximal  area  which  is 


APPENDICITIS  615 

sometimes  present  alone.  It  may  be  that  the  "appendix"  zone  is 
really  an  "appendix and  cecum"  zone,  because  the  cecum  is  so  fre- 
quently involved  in  appendicitis.  Sometimes,  when  an  ice-bag  has 
been  employed  over  the  appendix  region,  only  the  posterior  half  of 
the  zone  is  present. 

Diagnosis  has  been  aided  in  a  considerable  number  of  the  patients 
by  the  presence  of  the  zone,  especially  in  that  large  class  of  acute 
cases  in  which  the  abdomen  is  rigid  and  there  is  no  palpable  mass. 
The  zone  has  been  of  the  greatest  value  in  helping  to  differentiate 
between  diseases  of  the  appendix  and  those  of  the  gall-bladder  or 
right  uterine  adnexa. 

The  absence  of  a  zone  is  of  no  significance.  If  a  patient  com- 
plains of  symptoms  which  resemble  appendicitis,  and  a  zone  is  not 
present  in  the  right  lower  abdomen,  it  is  well  to  look  elsewhere  for 
hyperalgesia.  Thus  in  cases  of  beginning  pneumonia  that  had  con- 
siderable pain,  tenderness,  and  rigidity  in  the  right  iliac  region,  the 
presence  of  hyperalgesia  over  the  thorax  first  lead  to  careful  exami- 
nation of  the  lungs. 

•Intestines. — Head  gives  the  zone  as  corresponding  to  the  ninth, 
tenth,  eleventh,  and  twelfth  dorsal  segments  of  the  spine.  Elsberg 
does  not  find  these  uniform.  He  shows,  however,  uniform  zones  in 
ileocecal  tuberculosis  and  in  perforation  of  the  ileum. 

Ileocecal  Tuberculosis. — ^There  is  a  large  area  of  hyperalgesia 
occupying  the  whole  right  lower  abdomen  down  to  Poupart's  liga- 
ment, often  extending  a  little  to  the  left  of  the  median  line,  and 
posteriorly  becoming  lost  about  the  posterior  axillary  line. 

Perforation  of  the  Ileum. — The  zone  resembles  that  of  ileocecal 
tuberculosis,  but  extends  more  to  the  left  of  the  median  line. 

Uterus  and  Adnexa. — Head  describes  differences  between  the 
zones  for  the  uterus,  the  ovary,  and  the  tube.  Elsberg  differs  some- 
what: The  zone  for  the  right  adnexa  lies  on  the  right  half  of  the 
median  line;  that  of  the  left  adnexa  on  the  left  half;  the  zone  for 
the  uterus  is  a  combination  of  the  two.  There  is  no  dift'erence  be- 
tween the  zones  for  the  right  and  left  adnexa.  Beginning  some 
distance  above  Poupart's  ligament,  the  upper  margin  of  the  zone 
runs  parallel  to  it,  and  pursues  this  obliquely  upward  course  to  the 
spine  of  the  second  lumbar  vertebra  (approximately).  The  lower 
margin  is  a  long,  tongue-like  process  that  extends  half-way  down 
the  thigh  on  its  inner  aspect.  The  lower  margin,  as  it  passes  a 
short  distance  below  the  anterior  superior  spine  of  the  ileum,  ap- 
proaches the  upper,  the  average  breadth  of  the  zone  here  being 
3  inches.  The  lower  border  then  passes  horizontally  backward 
over  the  buttock  to  reach  the  posterior  median  line  partly  over  the 
sacrum.  Sometimes  the  upper  half  of  this  zone  is  better  developed, 
sometimes  the  lower;  these  may  be  considered  maxima. 

Diagnosis  in  the  diseases  of  the  uterus  has  not  been  aided  by 
the  presence  of  a  zone.     Elsberg  states  that  in  about  half  of  the 


6l6  DISEASES    OF   THE   STOMACH   AND   INTESTINES 

cases  of  dysmenorrhea  and  of  endometritis  with  pain,  the  zone  was 
present.  Some  of  the  cases  of  retroflexion,  retroversion,  anteflex- 
ion, and  prolapse  showed  the  zone.  It  was  present  in  the  5  cases 
of  uterine  polyp  that  he  observed  (all  of  them  had  pain).  It  was 
not  present  in  tumors  of  the  uterus,  except  in  a  few  cases. 

In  diseases  of  the  tubes  and  ovaries,  especially  those  of  the  right 
side,  the  zones  have  been  of  diagnostic  value. 

I  can  substantiate  these  observations  of  Elsberg  and  Neuhof, 
and  believe  that  the  tests^  for  Head's  zones  are  a  valuable  aid  in 
differential  diagnosis,  especially  in  appendicitis. 

Prognosis. — There  is  always  an  element  of  uncertainty  in  every 
case  of  appendicitis,  and  it  is  well  to  be  guarded  in  every  acute  case 
when  expressing  an  opinion;  for  an  apparently  simple  case  may 
suddenly  show  dangerous  or  even  fatal  symptoms.  It  is  a  well- 
know^n  fact  that  in  the  simple  catarrhal  cases  there  may  never  be  but 
one  attack,  perfect  recovery  resulting. 

Many  cases  of  exudation  or  abscess,  especially  of  the  old  cases  of 
so-called  perityphlitis,  have  recovered  without  operation. 

Sahli  has  collected  7213  cases;  of  these,  473  were  operated  on, 
6740  were  not. 

Of  the  latter,  591  (8.8  per  cent.)  died;  6194  (91.2  per  cent.)  re- 
covered; recurrences  took  place  in  4593  cases;  of  these  3653  recovered 
without  a  second  recurrence. 

Nothnagel  claims  that  80  per  cent,  of  cases  of  circumscribed 
appendicitis  recover  under  medical  treatment. 

The  fact  that  a  patient  has  recovered  under  medical  treatment 
from  one  or  two  attacks  during  a  period  of  several  years  is  no  guarantee 
that  a  fatal  issue  may  not  ultimately  occur.  If  a  simple  catarrhal 
attack  occurs,  with  moderate  symptoms  and  no  marked  changes  in 
the  blood,  the  prognosis  for  immediate  recovery  is  certainly  favor- 
able. If  no  attacks  occur  during  several  years,  the  chances  of  sub- 
sequent attacks  are  lessened.  In  all  statistics  of  a  second  attack 
and  subsequent  apparent  cure,  the  history  should  be  investigated 
for  some  years.  In  many  cases,  when  recurrence  has  taken  place, 
we  find  chronic  appendicitis  and  practically  invalidism  as  a  result. 

If  in  acute  cases  there  are  marked  blood  changes  with  high  poly- 
nuclear  count,  the  danger  is  imminent. 

Treatment. — The  medical  treatment  can  be  summed  up  very 
briefly.  Absolute  rest  in  bed  in  the  dorsal  position.  The  bowel 
and  urine  evacuation  should  occur  with  the  patient  confined  to  bed. 

The  physician,  having  made  his  diagnosis  of  acute  appendicitis, 
to  the  exclusion,  of  course,  of  general  peritonitis,  should  pursue  the 
following  course:  All  food  and  even  water  at  first  should  be  pro- 
hibited by  mouth.  No  cathartic  should  at  this  time  be  given. 
Thirst  can  be  relieved  by  rinsing  the  mouth  with  cold  water,  by 
small  rectal  injections  of  oij  to  iij  (60.0-90.0)  of  hot  normal  salt 
1  American  Journal  of  the  Medical  Sciences,  Nov.,  1908. 


APPENDICITIS  617 

solution  at  105°  to  108°  F.,  or  by  proctoclysis.  If  there  is  much 
distention,  or  if  nausea  or  vomiting,  lavage  should  be  carefully 
performed.  In  these  methods  I  agree  with  Ochsner.  In  the  fol- 
lowing I  differ.  If  the  lavage  does  not  markedly  relieve  the  distention 
(if  such  be  present),  I  would  then  advise  the  physician  to  person- 
ally gently  wash  the  bowel  with  tube  and  funnel,  after  the  method 
of  lavage.  Only  about  a  quart  of  normal  saline  in  all  at  110°  F., 
need  be  employed,  allowing  a  few  ounces  to  flow  in  and  then  siphon- 
ing it  out.  This  practically  mechanically  carries  off  the  gas  and 
has  little  influence  in  producing  active  peristaltic  action.  A  similar 
technic  is  employed  in  acute  distention  of  typhoid  fever  with  active 
hemorrhage.  He  should  carefully  note  the  patient's  temperature, 
the  rapidity  and  character  of  the  pulse,  and  the  ratio  of  pulse  to 
temperature.  When  feasible,  I  advocate  blood  examination  in  every 
case,  though,  of  course,  it  is  in  some  cases  impossible.  The  physician 
should  return  to  his  case  in  two  to  three  hours  for  the  purpose  of 
further  examination.  The  ice-bag  should  be  applied  to  the  painful 
area  at  the  first  visit. 

The  pain  in  almost  every  case  can  be  controlled  by  the  use  of  an 
ice-bag  of  light  weight  and  a  small  amount  of  ice  therein,  so  arranged, 
supported  by  a  circle  of  gauze,  that  only  the  sensitive  area  is  touched 
by  it.  A  thin  layer  or  two  of  gauze  can  be  placed  between  the  bag 
and  the  skin,  so  no  damage  can  be  done  b}'  the  cold,  which  should 
be  continuously  applied.  The  bag  can  also  be  suspended  from  a  barrel 
hoop  to  take  off  the  weight,  but  the  former  method  is  the  simplest. 

In  emergency  I  have  used  bits  of  ice  tied  up  in  dress  shields  or 
in  pieces  of  rubber  tissue  as  a  substitute  for  the  bag. 

On  the  following  visit  or  the  one  thereafter  (all  of  which  visits 
should  be  made  within  a  total  period  of  nine  to  ten  hours)  some 
definite  determination  as  to  the  proper  course  to  follow  at  that  spe- 
cific time  can  be  made.  Lavage  may  again  be  indicated  to  relieve 
distention,  or  even  the  special  intestinal  washing  as  previously  de- 
scribed. Frequentlv,  however,  under  abstention  from  food  and 
drink  and  the  application  of  ice,  the  tA'mpanites  will  be  markedly  re- 
lieved and  physical  examination  be  comparatively  easy.  If  there  is  a 
history  of  long  constipation,  and  on  examination  a  large  fecal  accumu- 
lation can  be  determined  in  the  cecum,  I  resort  to  radical  treatment. 

Fecal  accumulation  with  gaseous  distention  is  an  actual  danger, 
from  causing  pressure  on  the  inflamed  appendix.  I  always  resort  in 
such  cases  to  enema  or,  preferably,  gentle  intestinal  irrigation  once 
or  twice  a  day  every  dav  with  normal  saline  solution,  with  two  tubes 
or  a  recurrent  tube,  using  2  to  3  or  4  quarts  at  each  lavage,  only  \ 
pint  at  a  time,  at  110°  to  115°  F.,  emptying  the  large  intestine 
mechanically.  I  have  frequently  seen  the  acute  symptoms  rapidly 
subside  with  the  above  method.     These  cases  are  not  so  very  rare. 

At  the  end  of  forty-eight  hours,  with  symptoms  defervescing,  a 
dose  of  calomel  or  a  saline  is  then  indicated.     If  there  is  vomiting, 


6l8  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

oxalate  of  cerium  or  bismuth,  and  heat  to  epigastrium;  for  excess- 
ive vomiting,  lavage. 

The  type  with  fecal  impaction  is  the  only  class  of  cases  in  which 
such  radical  methods  are  resorted  to.  If  in  other  acute  cases  in 
the  course  of  the  first  ten  hours  the  temperature  does  not  rise 
markedly,  and  especially  if  the  pulse  does  not  increase  in  frequency, 
but  rather  diminishes,  and  its  character  improves,  with  improvement 
in  the  other  symptoms,  delay,  with  careful  watching  of  the  patient, 
is  allowable.  The  attack  then  may  gradually  entirely  subside  with 
no  subsequent  recurrence  or  a  fresh  attack  take  place  after  an  in- 
terval. In  the  case  of  a  first  attack  comparatively  mild,  I  would 
not  advise  operation  subsequent  to  the  attack  unless  the  patient 
contemplated  a  journey  beyond  the  reach  of  a  surgeon.  Interval 
operation  is  always  preferable.  The  indications  for  surgical  inter- 
vention are  given  on  page  619. 

Diet. — ^As  to  diet,  I  am  not  quite  as  radical  as  Ochsner  in  all 
cases.  For  two  days  in  the  acute  attack,  no  matter  what  the  type, 
I  allow  nothing  by  mouth,  neither  food  nor  water.^  The  mouth  is 
rinsed  and  hot  salines  given  by  enema  or  by  proctoclysis.  After  two 
days  I  allow  small  quantities  of  hot  water  by  mouth,  and  if  the  tem- 
perature is  100°  F.  or  over,  no  food  by  mouth,  but  nutritive  enemata. 
As  soon  as  the  temperature  falls  to  100°  F.  or  below,  food  is  given  by 
mouth,  in  small  quantities  at  first.  The  general  diet  should  then  be 
fluid  for  some  days;  no  gaseous  fluid  should  be  given.  Milk  well 
diluted  with  lime-water  or  equal  parts  with  barley-water,  oatmeal- 
water,  rice-water,  gruels,  etc.,  are  excellent.  Personally,  I  believe 
the  latter  methods  preferable  to  milk,  as  causing  less  tympanites;  as 
the  symptoms  subside,  eggs  beaten  up  with  milk,  bouillon,  chicken 
broth,  and  later  soft-boiled  eggs  and  milk-toast  are  added. 

I  agree  with  Ochsner  that  lavage  is  valuable  for  the  distention 
or  for  vomiting.  If  the  tympanites,  however,  is  not  relieved  by  the 
lavage,  I  believe  the  funnel  method  of  gentle  irrigation  of  the  bowel 
to  be  perfectly  safe.  If  fecal  accumulation  occur  later  during  the 
attack,  a  soapsuds  enema  is  indicated.  A  cathartic  should  not  be 
given  by  mouth  during  the  early  acute  stage  until  the  temperature 
falls  to  below  100°  F.  or  until  the  local  symptoms  defervesce. 
Fecal  impaction  is  the  exception.  Catarrhal  colitis  should  receive 
treatment  as  soon  as  the  acute  stage  of  appendicitis  has  subsided. 

Opium  has  long  been  a  much-vaunted  remedy,  on  the  theory  of 
quieting  peristalsis  and  allowing  adhesions  to  form ;  also  for  relieving 
pain;  and  given  preferably  as  laudanum,  or  by  suppository.  I  am 
absolutely  opposed  to  its  use.  The  character  of  the  pulse  and 
respiration  are  changed  thereby;  muscular  rigidity  will  relax;  and  I 
have  seen  the  symptoms  of  perforation,  both  of  the  appendix  and 
gall-bladder,  entirely  masked  by  its  employment.     Tympanites,  dis- 

1  This  checks  peristalsis,  as  Ochsner  claims,  and  furthermore  places  the  patient 
»in  the  best  condition  for  operation  should  such  suddenly  become  necessary. 


APPENDICITIS  619 

tention,  and  intestinal  paresis  are  more  apt  to  occur  as  a  result  of 
its  use.     The  application  of  heat  I  am  opposed  to. 

The  ice-bag  continuously  applied  possesses  all  advantages  and  no 
disadvantages;  and  I  only  advise  the  use  of  a  single  small  dose  of 
morphin  by  hypodermic,  and  find  it  but  seldom  necessary,  if  the  ice 
does  not  control  the  pain. 

Frequent  examinations  of  the  blood  as  regards  differential 
leukocytosis  and  hyperinosis  should  be  made  in  every  case  when 
possible,  at  first  at  least  twice  daily,  and  thereafter  once  a  day. 

If  the  differential  count  is  not  marked  and  does  not  increase,  but 
rather  diminishes,  and  the  symptoms  gradually  defervesce,  do  not 
operate  during  the  acute  attack. 

The  indications  for  operation  are  as  follows:  i.  If  the  patient 
shows  the  symptoms  of  acute  peritonitis  when  first  seen  or  suddenly 
develops  them — general  muscular  rigidity,  tender  abdomen,  tym- 
panites, etc. — operate  immediately. 

2.  If  there  be  found  on  examination  an  area  of  resistance  in  the 
right  iliac  fossa,  and  this  increases  with  more  marked  symptoms  after 
six  to  twelve  hours'  observation,  whether  chills  be  present  or  not, 
operation  is  indicated. 

An  aspirating  needle  should  never  be  employed  for  purposes  of 
diagnosis. 

The  blood-count  is  of  value  as  an  aid  to  prognosis  and  diagnosis, 
if  the  physician  has  the  technical  skill  or  can  have  it  done. 

3.  In  a  large  abscess,  in  complicated  cases,  or  when  temperature 
is  steadily  rising,  operate. 

4.  If  the  course  of  the  disease  is  protracted  and  the  symptoms 
point  to  abscess  or  an  active  and  progressive  process,  operate. 

5.  In  acute  fulminating  cases.  In  this  type,  with  apparently 
mild  local  symptoms,  but  especially  a  gradual  increase  of  pulse  and 
a  moderate  increase  of  temperature,  there  should  be  immediate 
operation.     The  blood  examination  is  important,  if  possible. 

6.  A  frequent  pulse,  increasing  in  rapidity,  not  corresponding 
to  the  more  gradual  rise  of  temperature,  indicates  operation.  In  all 
cases  when  the  differential  blood-count  is  marked  and  increasing, 
operate. 

7.  If  the  patient  have  a  mild  attack  and  subsequently  develop  a 
second  attack  (of  less  severe  type  than  the  first),  delay  may  occur; 
but  if  a  third  attack  occur,  then  an  interval  operation.  If  the  second 
attack  be  more  severe  than  the  first,  then  interval  operation. 

8.  In  chronic  appendicitis,  with  symptoms  persistent  and  in- 
validism, or  if  recurrent  acute  exacerbations,  operate. 

9.  In  harmful  involution  of  the  appendix,  operate. 

In  effect,  the  best  judgment  is,  operate  if  possible  during  interval; 
and  do  not  operate  if  one  or  two  mild  catarrhal  attacks. 

The  method  of  operation  depends  on  the  location  and  type  of 
appendicitis. 


CHAPTER  XXX 


DIVERTICULITIS— PERIDIVERTICULITIS 

{Synonyms. — Sigmoiditis ;  Perisigmoiditis. ) 

History. — During  the  past  fifty  years  specimens  of  false  diver- 
ticula of  the  descending  colon  and  sigmoid,  both  with  and  without 
concretions,  have  been  reported  by  pathologists,  who  have  demon- 
strated their  relationship  to  general  or  local  peritonitis.  Only 
recently  has  attention  been  especially  focused  on  inflammation  in 
the  left  iliac  fossa,  and  the  terms  "sigmoiditis"  and  'perisigmoidi- 
tis" been  employed. 


Fig.  223. — Diverticulitis.  Sigmoid  laid  open  longitudinally.  A  diverticulum 
containing  a  sloughing  ulcer  is  seen  at  the  lower  right  hand;  another  is  sectioned 
near  the  label  needle  (W.  J.  Mayo). 

There  is  confusion  as  to  the  definition  of  sigmoiditis,  many  using 
it  in  the  sense  of  a  catarrh  of  the  sigmoid ;  while  others  define  it  as  an 
inflammatory  condition,  involving  to  a  greater  or  less  degree  this 
entire  portion  of  the  gut  (the  musculature  included).  In  other 
words,  it  is  not  a  catarrh  of  the  mucous  membrane.  It  was  so 
defined  as  a  diffuse  inflammation  by  PateP  and  will  be  so  employed 
in  this  volume.     Eisendrath"  has  recently  contributed  to  this  subject. 

Diverticulitis'^  and  peridiverticuhtis,  as  when  productive  of 
disturbance  they  occur  chiefly  in  the  sigmoid,  have  been  used  inter 

1  Revue  de  Chirurgie,  Oct.  and  Dec,  1907;  Lyon  Med.,  Oct.  2,  1905. 

2  Specific  inflammations,  such  as  dysentery,  tuberculosis,  and  syphilis,  are 
excluded  (author). 

^Sigmoid  Diverticulitis,  Archives  of  Diagnosis,  Oct.,  1909. 

620 


DIVERTICULITIS — PERIDIVERTICULITIS 


621 


changeably   with    sigmoiditis;    and    perisigmoiditis   bears   the   same 
relationship  as  does  perityphHtis  to  typhUtis. 


Fig.  224. — Diverticulitis.     Section  through  ulcerated  diverticulum  shown  in  Fig. 

223  (W.  J.  Mayo). 

Mayo  first  employed  the  term  sigmoiditis,  but  the  condition  was 
first  described  by  Joseph  M.  Mathews.      J.  P.  Tuttle  ^  has  recently 


Fig.  225. — Diverticulitis.  Enlarged  view  of  sectioned  diverticulum  shown 
in  Fig.  223.  Note  rnuscularis  in  wall,  occluded  lumen,  and  inflamed  suhmucosa 
(W.  J.  Mayo). 

contribitted  an  excellent  monograph.     Though  inflamed   diverticula 

of  the  sigmoid  undoubtedly  cause  the  maximum  of  all  cases  of   sig- 

1  American  Journal  of  Surgery,  A])ril,  1909. 


622 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


moiditis  and  perisigmoiditis,  having  about  the  same  relation  to  left 
iliac  abdominal  suppuration  as  the  appendix  has  to  similar  condi- 


1^^,    ^ 

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Fig.  226.— Peridiverticulitis.  Sigmoid  divided  longitudinally.  Note  defect- 
ive musculature  and  the  diverticula.  Inflammatory  mass  dissected  away  near 
label  needle  (W.  J.  Mayo). 

tions  in  the  right  iliac  fossa,  yet  other  causes  of  perisigmoiditis  are 
given,  such  as  ulcerations  extending  through  the  wall  of  the  gut; 


Fig.  227. — Peridiverticulitis.     Enlarged  view  of  two  diverticula  and  one  point  of 
defective  musculature  seen  in  Fig.  226  (W.  J.  Mayo). 

traumatism  or  puncture  by  foreign  bodies;  diverticula,  in  association 

with  which   Byron  Robinson  and  Tuttle^  believe  that  traumatism 

^  American  Journal  of  Surgery,  April,  1909  (J.  P.  Tuttle). 


DIVERTICULITIS — PERIDIVERTICULITIS 


623 


from  the  iliac  and  psoas  muscles  play  a  part;  lumbricoid  worms 
and  wisps  of  hay  entering  the  appendices  epiploicae.  Secondary 
perisigmoiditis  is  also  believed  to  occur  from  inflammation  by  exten- 
sion from  other  abdominal  or  pelvic  organs. 

Wm.  J.  Mayo^  draws  a  sharp  distinction  between  diverticulitis 
and  peridiverticulitis  (Figs.  223-228). 

With  diverticulitis  there  is  a  primary  lesion  in  the  mucosa,  often 
of  ulcerative  type,  and  a  tendency  to  perforation  into  the  peritoneal 
cavity,  wdth  resulting  acute  peritonitis.  It  has  no  tendency  to 
produce  reduction  of  the  lumen  of  the  bowel. 

With  peridiverticulitis  there  is  a  leakage  of  toxins  and  bacteria 
into  the  subserosa  and  tissues  surrounding  the  diverticulum,  with 
resulting  inflammation  and  thickening  of  the  gut,  so  that  its  lumen 
may  be  markedly  reduced  and  symptoms  of  obstruction  occur. 
Perforative  peritonitis  rarely  occurs  in  this  type,  as  so  much  repara- 


Fig.  228.— Peridiverticulitis.     Sketch  of  diverticulum  with  inflammatory  deposit 
in  subserosa;   11  diam.  (W.  J.  Mayo,  Wilson,  and  Giffin). 

tive  inflammation  goes  on.     Local  intraperitoneal  abscess  or  acute 
or  chronic  obstruction  may  result. 

Lejars,^  Bittorf,^  and  Rosenheim*  classify  sigmoiditis  and  peri- 
sigmoiditis clinically.  Gordinier  and  Sampson^  hold  that  these  con- 
ditions are  more  frequent  than  we  suppose. 

Diverticula  of  the  Intestines. — Diverticula  are  formed  by  a. 
bulging  or  protrusion  of  the  intestinal  wall,  and  are  divided  into  the 
congenital  and  the  acquired. 

In  the  congenital  forms  the  wall  of  the  diverticulum  is  formed  by 
the  whole  intestinal  wall;  and  these  have  been  called  "true"  diver- 

1  vSurgery,  Gynecology,  and  Obstetrics,  July,  1907. 

2  Semaine  Medicale,  June  27,  1904,  p.  26. 

3  Miinchener  med.  Wochenschr.,  1904,  p.  147. 

^  Zeitschr.  fiir  Klin.  Med.,  1904,  Band,  liv,  p.  475. 
5  Jour.  Am.  Med.  Assoc,  1906,  vol.  i,  p.  1686. 


624 


DISEASES    OE   THE    STOMACH   AND   INTESTINES 


ticula.  It  was  formerly  thought  that  all  acqtKfred  diverticula  were 
of  the  "false"  type,  consisting  of  protrusions  of  the  mucosa  through 
spaces  in  the  muscular  coat,  so  that  their  wall  comprised  mucosa 
and  serosa.  It  has  been  demonstrated  that  acquired  diverticula 
may  be  of  the  "true"  type,  and  are  caused  most  frequently  by 
traction  from  tumors  or  adherent  organs.  False  diverticula  are  the 
result  of  excessive  pressure  within  the  intestines  combined  with  a 
congenital  weakness  of  the  bowels.  The  chief  congenital  diver- 
ticulum of  importance  is  Meckel's. 

Meckel s    diverticiihim,    due    to    the    persistence    or    incomplete 
obliteration  of  the  omphalomesenteric  duct,  usually  rises  from  the 


229. — Hodenpyl's  specimen  of  multiple  acquired  diverticula  of  the  colon 
(sigmoid  flexure)  (Brewer). 


ileum  ^  to  I  meter  above  the  ileocecal  valve,  from  the  convex  margin 
of  the  intestines  opposite  the  mesenteric  attachment,  and  varies  in 
length  from  3  to  10  cm.,  though  rarely  longer. 

Congenital  diverticula  have  been  found  in  the  small  and  large 
intestines. 

Acquired  diverticula  occur  both  in  the  small  and  large  intestines, 
and  have  even  been  recorded  in  the  appendix  by  EdeP  and  JNIertius.^ 

They  are  generally  more  frequent  in  the  large  intestine,  especially 
in  the  lower  part  of  the  descending  colon  and  sigmoid  flexure,  the 

1  Virchow's  Archiv.,  Bd.  cxxxviii. 

2  Mitheilung  ans  der  Grenzgebiet  fiir  Med.  und  Chur.,  Bd.  ix. 


DIVERTICULITIS — ^PERIDIVERTICULITIS  625 

latter  providing  the  most  examples,  as  in  Fig.  228,  reported  by  G. 
Brewer.^     Here  they  are  usually  multiple. 

Autopsies  in  death  from  other  causes  have  been  reported  where 
diverticula  were  found,  but  no  symptoms  had  ever  occurred.  As 
many  as  400  diverticula  in  one  case  have  been  noted  by  Hausemann. 

One  case  of  diverticulitis  of  the  small  intestine  which  gave 
symptoms  has  been  recorded  by  Gordinier  and  Sampson.- 

With  diverticula  of  the  appendix,  appendicitis  has  been  simulated, 
but  it  is  clinically  unimportant  to  separate  the  conditions,  as  opera- 
tion is  indicated  in  any  event.  Diverticula  are  most  frequent  in 
the  sigmoid  flexure.  Quite  a  number  give  important  symptoms. 
E.  Beer^  has  described  the  clinical  symptoms  of  diverticulitis  and 
Telling^  has  collected  105  cases,  giving  a  thorough  exposition  of  the 
subject. 

Sudsuki^  found  diverticula  present  15  times  in  40  autopsies, 
so  that  the  condition  is  probably  more  frequent  than  has  been  sup- 
posed, and  has  often  been  overlooked,  even  in  post  mortem. 

Brewer^  has  reported  a  case  of  acute  diverticulitis  of  the  sigmoid, 
with  operation  before  rupture. 

Occurrence. — Acquired  diverticula  are  much  more  common  in 
the  large  intestine,  more  so  in  the  descending  colon,  and  especially 
so  in  the  sigmoid  flexure.  They  are  usually  multiple  and  may  arise 
from  any  part  of  the  surface.  They  are  frequently  seen  in  two 
rows  at  the  sides  of  the  gut,  or  close  to  the  mesenteric  attachment, 
more  rarely  on  the  convexity. 

Chlumsky  claims  that  he  finds  by  experiment  that  rupture  in  the 
living  bowel  upon  distention  occurs  more  frequently  opposite  the 
mesentery.  The  general  opinion  is  that  the  mesenteric  side  is  less 
resistant.  Probably  the  most  common  occurrence  of  these  diver- 
ticula is  in  the  appendices  epiploicae.  In  many  cases  they  are  con- 
fined to  them,  and  present  a  double  row  of  symmetrically  placed 
hollowed-out  pockets.  In  other  cases  none  are  so  situated,  and  fre- 
quently some  enter  the  appendices  and  some  lie  outside  of  them. 
The  presence  of  the  diverticula  in  these  appendices  may  account  for 
some  of  the  tenderness  found  in  many  portions  of  the  gut.  The 
special  favoring  of  the  epiploicge  is  accounted  for  by  the  fact  that 
the  point  of  their  attachment  to  the  gid  is  a  place  of  least  resistance. 

In  a  majority  of  cases  the  affected  appendages  have  been  or  are 
filled  with  a  large  amount  of  fat. 

Bland  vSutton''  has  stated  and  illustrated  by  diagrams  that  this 
fat  is  directly  continuous  with  the  subserous  fat.     If  there  is  the 

1  Am.  Jour,  of  Med.  Sci.,  Oct.,  1907. 

2  Jour.  Am.  Med.  Assoc,  1906,  vol.  i,  p.  i6<S4. 
^  Am.  Jour,  of  Med.  vSci.,  July,  1904. 

^  Lancet,  March  21  and  28,  1908. 
'  Langenbeck's  Archiv.,  Bd.  Ixi,  p.  708. 
8  Jour.  Am.  Med.  Assoc,  Aug.  15,  1908. 
'  Lancet,  Oct.  24,  1903,  p.  1148, 

40 


626'  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

slightest  tendency  to  the  formation  of  diverticula,  it  will  readily 
be  seen  that  the  soft  fatty  tissue  of  the  appendices  epiploicae  form 
a  point  of  lowered  resistance. 

Size. — The  diverticula  vary  in  size  from  a  millet-seed  to  a  hazel- 
nut. Large  size  is  seldom  attained,  as  secondary  changes  occur 
leading  to  detachment,  ulceration,  abscess,  or  peritonitis. 

When  small,  they  are  semiglobular ;  as  they  increase  in  size,  more 
oval  or  flask  shaped;  the  aperture  on  the  gut  wall  usually  being 
smaller  than  the  maximum  diameter  of  the  diverticulum,  and  almost 
constantly  so  when  they  enter  the  appendices  epiploicae. 

This  is  an  anatomic  point  of  great  importance  in  regard  to  the 
causation  of  inflammation.  In  those  which  do  not  enter  the  ap- 
pendices the  aperture  may  be  relatively  large.  They  are  then  gener- 
ally true  diverticula  and  are  formed  from  normal  haustra  (Sudsuki)  ,^ 
usually  not  extending  much  above  the  middle  of  the  descending  colon. 
They  increase  in  number  and  size  from  above  downward,  and  may  be 
quite  crowded  together  in  the  sigmoid  flexure.  At  the  commence- 
ment of  the  rectum  they  generally  stop  abruptly.  This  is  possibly 
due  to  the  absence  of  appendices  epiploicae  in  this  situation ;  but  the 
fact  that  the  feces  are  not  retained  so  long  in  this  part  of  the  bowel 
is  also  partly  responsible.  Schreiber^  thinks  that  the  stronger  mus- 
culature of  the  rectum  plays  some  part  in  preventing  their  formation. 

They  are  almost  invariably  filled  with  fecal  material,  generally 
concretions  of  some  degree  of  firmness.  This  fact  probably  deter- 
mines their  subsequent  clinical  importance,  and  sharply  distinguishes 
them  from  acquired  diverticula  in  the  small  intestine,  which  rarely 
contain  fecal  material.  To  this  we  can  ascribe  the  immunity  of  the 
latter  from  secondary  pathologic  processes  and  symptoms. 

Usually  in  the  early  stages  all  the  coats  of  the  bowel  are  repre- 
sented, but  in  some  the  muscularis  is  absent.  There  has  been  con- 
troversy as  to  the  presence  or  absence  of  muscular  fibers  in  the 
diverticulum  wall.  Cruveilhier  and  Rokitansky  originally  regarded 
the  diverticula  as  hernial  protrusions  of  the  mucous  and  serous  coats, 
with  absence  of  muscular  tissue.  The  presence  or  absence  of  muscle 
was  for  many  years  the  criterion  for  distinction  between  congenital 
and  acquired  diverticula. 

The  microscopic  findings  in  numerous  cases  show  that  acquired 
diverticula  often  have  all  the  coats  of  the  bowels  represented.  In  the 
early  stages  of  the  formation  it  is  almost  the  rule,  although  the  mus- 
cular tissue  undergoes  atrophy  as  the  sac  enlarges. 

Etiology. — One^  case  has  been  so  far  recorded  in  a  child,  while  the 
great  majority  are  in  old  or  even  aged  subjects.  They  seem  to  be 
generally  acquired. 

1  Langenbeck's  Archiv.,  Band.  Ixi,  p.  708. 

2  Deutsche  Archiv.  fur  KHn.  Mediciti,  1902,  p.  122. 

3  In  a  child  seven  years  of  age  an  acute  catarrhal  inflammation  of  divertic- 
ula in  the  sigmoid  occurred  (Annals  of  Surgery,  vol.  xlvii,  by  A.  P.  C.  Ashhurst). 


DIVERTICULITIS — PERIDIVERTICULITIS  627 

1.  Generally,  advanced  age  of  the  patient.  In  80  cases,  average 
age  sixty  years,  but  of  those  in  whom  diverticula  caused  symptoms 
in  47  cases,  the  age  was  fifty-five  years.  In  33  cases  no  symptoms 
were  referred  to  their  presence,  but  they  were  accidentally  discovered, 
the  age  was  sixty-seven.  Fiedler^  records  the  youngest  case  at 
twentv-two  years.  William  J.  Mayo  places  the  majority  at  over 
fifty  years. 

2.  Sex. — In  81  cases — 53  males,  28  females. 

3.  Obesity. — Klebs,  Mayo,  and  others  have  laid  stress  on  this. 
Many  have  been  fat;  the  presence  of  much  fatty  tissue  in  the  gut 
walls  and  appendices  epiploicae  have  been  shown  by  Bland  Sutton 
to  predispose  to  mucosal  out-pushings.  In  22  cases,  17  were  stated 
to  be  more  or  less  obese  and  to  have  much  fatty  tissue  in  the  gut 
wall. 

4.  Cachexia  and  Absentee  of  Fat. — On  the  other  hand,  many  sub- 
jects are  noted  as  having  been  thin  (Hausemann)^ ;  5  of  the  22  cases 
were  stated  to  be  of  this  type.  Undoubtedly  some  had  previously 
been  obese,  and  from  age  or  illness  had  lost  much  of  their  fatty 
tissue.  This  has  not  been  definitely  referred  to.  It  will  be  readily 
understood  that  the  fatty  deposit  would  first  weaken  the  gut  wall; 
the  subsequent  loss  of  fat  with  possible  concomitant  weakening  and 
wasting  of  the  muscle  fibers  would  probably  increase  this  tendency. 

5.  TJie  Normal  Structure  of  the  Large  Intestine. — This  readily 
lends  itself  to  local  yielding  of  its  walls,  as  is  suggested  by  the  normal 
sacculi,  which  are  often  exaggerated  in  cases  of  constipation,  sometimes 
in  association  with  diverticula. 

6.  Physiologic  Role  of  the  Sigmoid  Flexure. — In  this  portion  of  the 
bowel  is  the  longest  retention  of  fecal  material,  and  here  consequently 
the  pressure  from  within  will  be  liable  to  be  the  greatest.    . 

7.  Pressure  from  Within  the  Bowel. — ^This  may  be  due  to  accumu- 
lation of  feces  or  gas,  or  both. 

(a)  Presence  of  Constipation. — This  stands  in  7nost  frequent  and 
important  causal  relationship  to  this  condition.  In  22  cases  in  which 
the  point  is  definitely  mentioned,  constipation,  often  severe  and 
generally  for  a  considerable  period,  was  present  in  17.  In  the 
remaining  5  its  absence  was  particularly  noted.  Constipation  in  old 
people,  whether  obese  or  emaciated,  is  very  common,  while  diverticula 
are  comparatively  rare;  hence,  other  factors  must  be  present. 

{b)  Flatulence. — This  is  usually  associated  with  constipation,  and 
acts  in  the  same  way  by  increasing  internal  pressure;  so  much  stress 
has  been  laid  on  the  factor  of  internal  pressure  that  the  term  "pul- 
sion diverticula"  has  been  applied  to  them. 

8.  The  Relation  of  the  Diverticula  to  the  Points  of  Kniry  of  the 
Vessels  through  the  Gut  Walls. — This  fact  was  first  pointed  out  by 
Klebs^  in  the  case  of  acquired  diverticula  in  the  small  intestine,  and 

1  Denkschrift  der  Gesellschaft  fxir  Natur,  v.  Heilknade,  Dresden,  1S68. 

2  Virchow's  Archiv.,  Hand,  cxliv.  ^Pathologic  Anatomy,  1S69,  p.  271. 


628  DISEASES   OE  THE   STOMACH  AND   INTESTINES 

has  been  confirmed  by  others  (Hausemann  and  Fisher)  with  regard 
to  the  large  intestine. 

Microscopically  it  is  evident  that  the  spots  in  the  gut  wall  where 
it  is  pierced  by  the  vessels  are  areas  of  weakened  resistance  to  internal 
pressure,  because  the  vessels  are  accompanied  by  a  certain  amount 
of  lax  connective  tissue,  through  which  an  out-pushing  of  the  mucous 
membrane  can  more  easily  take  place. 

9.  Variations  in  the  Size  of  the  Vessels. — Graser'-  was  the  first 
to  investigate  this  point.  In  his  case,  the  patient  suffered  from 
chronic  heart  disease,  with  venous  back-pressure,  leading  to  dis- 
tention of  the  veins  in  the  gut  wall.  This  dilatation  he  regarded 
as  further  weakening  the  vessel  spaces  by  pushing  aside  the  muscular 
fibers.  He  examined  microscopically  the  sigmoids  of  28  patients 
who  had  suffered  prior  to  death  from  mesenteric  venous  stagnation. 
In  10  of  them  he  found  definite  evidence  (mostly  microscopic) 
of  commencing  out-pushings  of  the  gut  wall;  and  in  every  case  they 
occurred  through  these  "vessel  holes." 

The  diverticula  were  most  numerous  in  the  sigmoid  and  practi- 
cally ceased  at  the  middle  of  the  ascending  colon. 

Mesenteric  venous  congestion  may  be  due  to  chronic  heart  or  lung 
disease,  portal  back-pressure,  or  intra-abdominal  tumor,  etc. 

"  He  is  inclined  to  ascribe  a  special  importance  to  a  distention  which 
is  not  constant,  but  of  frequent  repetition,  as  recurs  in  the  repeated 
failures  of  cardiac  compensation  and  in  f '-equent  recoveries  therefrom 
in  patients  with  chronic  heart  disease." 

When  the  vessels  are  engorged  the  vessel  holes  are  enlarged; 
when  they  are  smaller  these  areas  are  thereby  weakened,  and  there 
is  a  greater  liability  to  hernia  of  the  mucosa. 

While  in  the  small  intestine  the  diverticula  are  practically  always 
on  the  mesenteric  side  of  the  bowel  where  the  vessels  pierce  the  walls, 
in  the  larger  bowel  many  of  the  diverticula  occur  on  the  side  remote 
from  the  mesentery.     Another  explanation  must  be  sought  for. 

Therefore,  Schreiber  believed  the  congestion  of  the  vessels  was 
secondary  to  the  presence  of  feces  in  the  diverticulum,  rather  than  to 
the  original  cause  of  the  formation  of  the  latter. 

10.  The  Connective  Tissue  Around  the  Vessels. — Sudsuki-  found  in 
40  cases  not  suffering  from  mesenteric  venous  stagnation  which  he 
examined  microscopically,  diverticula  present  in  15  bodies;  in  6  cases, 
true  diverticula,  that  is,  all  the  coats  were  therein.  In  20  cases,  where 
mesenteric  congestion  was  present,  he  found  diverticula  in  only  6;  in 
12  cases  free  from  congestion,  diverticula  were  found  in  9. 

The  subjects  were  all  adults  and  nearly  all  men,  middle  aged  or 
old.  He  suggests  there  is  a  congenital  predisposition  with  regard  to 
the  a77iount  and  laxity  of  connective  tissue  surrounding  the  vessels  at 
these  spots:  if  there  is  much  fatty  deposit,  this  will  act  in  the  same  way; 

1  Centralblatt  fiir  Chirurg.,  1898,  etc. 

2  Langenbeck's  Archiv.,  Band.  Ixi,  p.  708. 


DIVERTICULITIS^PERIDIVERTieULlTlS  629 

and  if  there  be  subsequent  wasting  of  such  fatty  tissues,  further 
weakening  takes  place. 

Beer  states  that  this  theory  fails  to  explain  the  non-mesenteric 
diverticula  and  those  which  have  muscular  layers  in  their  walls. 
These  vessel  spaces  have  some  influence,  but  they  have  some  addi- 
tional cause,  and  Beer  finds  this  in  the  following: 

II.  Muscular  Deficiency  of  the  Gut  Wall. — Since  diverticula  occur 
in  old  people,  in  whom  the  muscular  power  of  their  intestines  has  been 
more  or  less  exhausted  (as  evidenced  by  constipation),  and  are  in 
association  with  obesity  (or  obesity  followed  by  cachexia),  these 
facts  all  point  to  a  muscular  deficiency. 

In  this  muscular  weakness  Beer  thinks  the  cause  of  the  false 
diverticula  must  be  sought. 

In  ]Mayo's  cases  areas  of  muscular  deficiency  were  noted  opposite 
early  diverticula,  or  even  in  areas  yet  free  from  out-pushing.  Prob- 
ably no  one  factor  is  sufficient. 

Out  of  105  cases  reported,  60  per  cent,  w^ere  attended  with 
symptoms  (TelHng). 

Secondary  Pathologic  Processes  in  the  Diverticula. — The 
diverticula  of  themselves  occasion  no  symptoms,  but,  as  one  would 
expect,  readily  undergo  inflammatory  changes  therein.  They  tend 
in  most  cases  to  form  fusiform  pouches  connecting  with  the  lumen 
of  the  gut  by  a  constricting  neck,  and  these  pouches  are  situated  for  the 
most  part  on  that  portion  of  the  bowel — the  sigmoid  flexure — of 
which  the  normal  anatomy  and  physiology  favor  most  the  retention 
of  feces  and  the  accumulation  of  gas.  If  a  condition  of  constipation 
exists  and  the  "force  from  within"  is  increased,  it  is  almost  inevitable 
that  they  will  from  the  first  have  fecal  contents. 

On  account  of  the  narrow  neck  and  deficient  muscular  fibers  in 
the  sac  wall  the  contents  rarely  are  expelled  and  concretions  form. 
These  probably  cause  the  trouble.  The  first  result  would  be  a  tendency 
to  enlargement  of  the  sac.  Then  the  muscular  layers  atrophy,  as  do 
the  glands;  the  muscle  may  be  replaced  by  fibrous  tissue.  The  in- 
crease in  the  size  of  the  diverticulum,  with  atrophic  changes  in  its 
walls,  produces  necessarily  a  dangerous  thinning  of  the  sac.  In  some 
cases  there  is  little  more  than  a  peritoneal  covering,  with  the  con- 
tained feces  visible  through  it.  The  irritation  of  the  retained  and 
hardened  feces  then  leads  to  inflammatory  changes.  These  may  be 
slight  and  only  microscopic  in  the  mucosa  and  submucosa,  or  may 
produce  more  serious  acute  or  chronic  lesions.  The  fecal  matter  is 
a  nidus  for  bacteria ;  their  products  undoubtedly  determine  the  nature 
of  the  inflammatory  reaction  which  occurs.  An  ulceration  may 
result  from  bacterial  infection.  Moreover,  the  concretion  will  tend 
to  be  forced  through  an  inflamed  or  ulcerated  area.  These  features 
explain  the  occurrence  of  local  abscess  or  general  peritonitis.  The 
latter  may  be  also  the  result  of  sudden  trauma  or  strain,  which  may 
cause  an  increased  pressure  within  the  bowel. 


630  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

Definite  types  are  produced  by  the  following  causes  (Telling) : 

1.  Thinning  of  the  diverticulum  wall. 

2.  Perforating  action  of  the  retained  concretion. 

3.  The  presence  of  micro-organisms  and  their  toxins. 

4.  Inflammatory  reaction  of  varying  types  and  degree. 

With  these  data^  one  can  forecast  the  various  cases  which  one 
might  expect  clinically;  viz. : 

1 .  Infection  of  the  general  peritoneal  cavity  from  thinning  of  the 
sac  walls  without  perforation. 

2.  Acute  or  gangrenous  inflammation— "diverticulitis." 

3.  Chronic  proliferative  inflammation,  with  thickening  of  the 
gut  w^all  and  stenosis  of  the  bowel. 

4.  Formation  of  adhesions,  especially  to  the  (a)  small  intestine, 
(b)  bladder. 

5.  Perforation  of  diverticula,  giving  rise  to  (a)  general  peritonitis, 
(b)  local  abscess,  (c)  submucous  fistulae  of  the  gut  wall,  (d)  fistulous 
communication  wdth  other  viscera,  especially  the  bladder. 

6.  The  lodgment  of  foreign  bodies.  7.  Chronic  mesenteritis  of 
the  sigmoid  loop.  8.  Local  chronic  peritonitis.  9.  ]\Ietastatic  sup- 
puration. 10.  Development  of  carcinoma.  11.  Perforation  into  a 
hernial  sac. 

The  following  classification,  by  Telling,  I  believe  the  most  scientific : 

1.  Infection  of  the  general  peritoneum  as  a  result  of  thinning  of 
sac  walls.  Organisms  make  their  way  through  the  wall  and  cause 
peritonitis  without  perforation.     Loomis^  records  i  case. 

2.  Acute  Gangrenous  Inflammation  of  the  Diverticulum. — Symp- 
toms.— Pain,  tenderness,  and  swelUng  in  the  left  inguinal  region  are 
present.  Local  abscess  or  general  peritonitis  may  result.  Rigidity 
of  the  left  rectus ;  fever ;  hyperinosis  (increased  fibrin  in  the  blood) ; 
leukocytosis;  increase  in  polynuclears  are  present.  If  general  peri- 
tonitis, we  have  the  additional  s^Tnptoms. 

3.  Chronic  Inflammation. — A  chronic  proliferative  inflammation 
of  the  submucous  and  serous  coats  may  occur.  Thickening  may  be 
considerable.  It  may  lead  to  (a)  tumor  formation,  (b)  stenosis  with 
obstruction,  (c)  mimicry  of  carcinoma. 

This  type  of  inflammation  is  most  important,  most  frequent, 
and  generally  overlooked.  Grasser^  in  1898  first  described  a  case. 
Moynihan  recorded  one.  The  mimicry  of  carcinoma  is  so  perfect  that 
not  only  is  the  diagnosis  made  during  fife  but  also  at  the  operation, 
and  again  confirmed  erroneoush"  at  post  mortem. 

'  Eisendrath  gives  a  somewhat  simpler  clinical  classification: 

1.  Acute:  (a)  Acute  catarrhal;  (5)  acute  gangrenous,  with  or  without  local 
abscess:   (c)  acute  perforative,  with  general  peritonitis. 

2.  Chronic:  (a)  Chronic  hyperplastic  or  stenosing  (peridiverticulitis);  (6) 
enterovesical  fistulous  form;  (c)  chronic  adhesive  form,  causing  acute  or  chronic 
obstruction. 

2  New  York  Medical  Record,  1870,  vol.  iv. 

3  Centralblatt  fiir  Chirurg.,  1898. 


DIVERTICULITIS — PERI  DIVERTICULITIS  63 1 

Diflferential  diagnosis  between  carcinomatous  stenosis  and  diver- 
ticular stenosis  is  as  follows : 

With  carcinoma  there  are  nearly  invariably  an  involvement  and 
ulceration  of  the  mucous  membrane,  with  fungation  of  growth  into 
the  lumen  of  bowel.  With  diverticulitis  it  is  the  rule  for  the  mucous 
membrane  to  be  free  from  ulceration  (unless  a  fistulous  tract  or  abscess 
cavity  open  into  it  from  without  inward) ;  also  the  folds  of  the 
mucosa  are  stronglv  marked  and  crowded  together,  giving  an  unduly 
rugose  appearance.  The  orifices  of  the  pouches  may  be  visible,  but 
are  generally  small  and  often  concealed  by  these  folds.  One  should 
examine  the  folds  with  a  fine  probe.  There  is  usually  absence  of 
blood  and  pus  in  the  stool  in  diverticulitis,  but  present  in  carcinoma. 

Age  of  patients  the  same. 

Stenosis  may  cause  acute  or  chronic  obstruction  (Mayo). 

4.  Formation  of  Adhesions.^ {a)  Adhesions  to  small  intestine  may 
produce  acute  or  chronic  obstruction.  (&)  Adhesions  to  bladder  are 
also  noted. 

5.  Perforation  of  Diverticula. — Results  differ,  according  to  (a) 
acuteness  of  ulcerative  process,  {b)  amount  of  chronic  inflamma- 
tory thickening  present,  (c)  presence  of  adhesions. 

These  factors  determine  whether  perforation  leads  to  (a)  general 
peritonitis,  {b)  local  abscess  formation,  (c)  fistulous  communication 
with  other  viscera,  notably  the  bladder. 

(a)  General  perforative  peritonitis  has  occurred  in  14  cases.  C  A. 
McWilliams  reported  a  case  at  the  Surgical  Society,  October  30,  1907, 
which  he  operated  upon  at  the  Presbyterian  Hospital  for  general 
peritonitis;  the  history  of  constipation  of  only  a  week's  duration. 
Male,  age  forty-seven.  The  case  was  believed  to  be  perforative 
appendicitis,  not  having  been  seen  until  general  peritonitis  was  in 
evidence. 

Milky  fluid  under  considerable  tension  was  evacuated  at  operation. 
There  was  also  fluid  between  the  liver  and  diaphragm.  Appendix, 
gall-bladder,  stomach,  and  pancreas  were  examined,  but  no  per- 
foration was  found. 

The  patient's  condition  became  such  that  further  search  was 
deemed  inadvisable.  Post  mortem  showed  diverticula  of  large  size 
commencing  in  the  ascending  colon.  In  the  descending  colon,  10 
cm.  below  the  splenic  flexure,  a  perforation  of  a  diverticulum  was 
discovered.     Culture  from  the  peritoneum,  etc.,  showed  Bacillus  coli. 

ib)  Local  Abscess  Formation  in  24.  Cases. — There  may  be  several 
small  abscesses  shut  off  by  thick  adhesions  or  a  single  large  abscess. 
The  abscess  may  be  intra-  or  extraperitoneal,  and  may  lead  in  turn 
to  communication  with  the  external  surface,  with  the  bladder  or 
bowel. 

(c)  Submucous  Fistulcs. — In  some  cases  with  much  inflammatory 
thickening  the  ulceration  of  the  inside  of  the  sac  leads  to  a  small 
abscess.     This  happens  in  several  foci  in  the  thickened  area.     These 


632  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

abscesses  tend  to  burrow  through  the  thickened  tissues  and  form 
submucous  fistulous  communications  with  each  other.  There  may  be 
a  labyrinth  of  such  tracts.  They  may  re-enter  the  lumen  of  the 
sigmoid  or  communicate  with  a  peritoneal  abscess- cavity  by  one  or 
several  openings.  This  suppurating  process  is  often  excessively 
chronic  and  gives  rise  to  great  thickening,  adhesions,  and  tumor 
formation,  with  sequelae  in  the  shape  of  intestinal  obstruction  or 
adhesions  to  and  subsequent  perforation  of  the  bladder. 

6.  Lodgment  of  Foreign  Bodies. — Diverticula  are  liable  to  harbor 
foreign  bodies,  which  may  give  rise  to  perforation,  diverticulitis,  or 
local  abscess.     Bland  Sutton  reports  several  cases. 

7.  Chronic  Mesenteritis. — In  some  there  is  inflammatory  thick- 
ening of  or  abscess  formation  in  the  sigmoid  mesentery.  It  is  be- 
lieved by  Ries^  that  retraction  of  the  sigmoid  loop  is  produced  there- 
by and  also  adhesions,  and  hence  twists,  kinks,  or  volvulus. 

8.  Local  Chronic  Peritonitis. — ^This  is  often  found  in  the  neigh- 
borhood of  the  sigmoid,  causing  thickening,  opacity,  or  adhesion  of 
the  peritoneum,  probably  in  some  cases  due  to  leakage  of  toxins 
through  the  thin  wall  of  an  overlooked  diverticulum,  though  at  times 
due  to  the  pelvic  organs. 

9.  Metastatic  Suppuration. — One  case  recorded,  with  abscesses  of 
the  liver  from  diverticular  abscess  (Whyte).^ 

10.  Development  of  Carcinoma. — Secondary  to  diverticulitis. 
Carcinoma  may  result  from  chronic  irritation  and  ulceration  of 

diverticula  due  to  retained  feces  (Hochenegg^) . 

11.  Perforation  of  a  Hernial  Sac. — One  case  recorded  (Stierlin*). 

Clinical  Aspects. — Patel,^  in  discussing  inflammation  of  the  sig- 
moid, classifies  these  conditions  as  acute  non-suppurative  sigmoid- 
itis, suppurative  perisigmoiditis,  chronic  perisigmoiditis,  sigmoiditis, 
and  sigmoiditis  with  general  peritonitis. 

Inflammatory  trouble,  more  or  less  acute  in  the  left  lower 
abdomen,  has  been  described  as  left-sided  appendicitis,  sigmoiditis, 
perisigmoiditis,  epiploicae  appendicitis,  diverticulitis,  or  peridivertic- 
ulitis. 

Clinically,  the  acute  cases  resemble  appendicitis,  except  for  the 
fact  that  the  inflammation  is  on  the  left  side.  The  symptoms  are 
as  follows: 

Pain;  constipation;  tenderness  on  pressure;  muscular  rigidity, 
especially  of  the  left  rectus,  and  later  tumor;  local  tympanites  is 
present.     Tumor  is  not  always  present. 

Left-sided  Tumor  and  Abscess  Formation. — In  63  cases  tumor 
was  felt  in  20,  and  abscess  formation  occurred  in  23.     In  some  cases 

1  Annals  of  vSurgery,  vol.  xi,  p.  523. 

2  Scottish  Medical  and  Surgical  Journal,  1906. 

^  Verhandlungen  der  Deutsche  Gesellschaft  fiir  Chirurg.,  Thirty-first  Congress, 
1902,  p.  402. 

4  Correspondenzblatt  fur  Schweitzer  Aertze,  1902,  vol.  xxxii,  p.  749. 
^  Revue  de  Chirurgie,  Oct.  10,  1907,  and  Dec.  10,  1907. 


DIVERTICULITIS — PERIDIVERTICULITIS  633 

with  considerable  pus  formation  there  may  be  but  Httle  pain  and  no 
pyrexia  (Georgi). 

Tumor  is  elongated,  sausage  shaped,  tender,  and  often  ill  defined. 
It  may  be  movable  or  fixed,  lying  a  little  above  Poupart's  ligament 
(frequently  parallel  with  it). 

Shortly  after  the  occurrence  of  symptoms,  this  swelling  may  be 
made  out;  it  may  disappear  rapidly  or  gradually,  or  may  increase 
with  signs  of  pus  formation.  Patel  has  shown  that  the  tumor  may 
be  higher,  lower,  or  posterior.  The  position  depends  on  the  location 
of  the  inflamed  diverticulum.  In  a  patient  of  middle  age  or  older, 
diagnosis  of  diverticulitis  would  be  probable. 

Differential  diagnosis  must  be  made  from  appendicitis,  with  left- 
sided  S3^mptoms,^  pelvic  inflammation,  ovarian  cyst,  with  inflamma- 
tion or  strangulation,  actinomycosis  of  the  sigmoid,  syphilitic  or 
tuberculous  pericolitis,  sigmoid  catarrh,  and  dysentery.  Tubercu- 
losis is  too  often  accepted. 

Intestinal  Obstruction. — When  acute,  this  is  probably  due  to 
secondary  involvement  of  a  coil  of  small  intestine  and  is  not  to  be 
diagnosed  except  at  operation. 

The  same  is  true  of  chronic  obstruction  of  the  small  intestine. 
Obstruction,  which  is  chronic,  recurrent,  or  acute  engrafted  on  chronic, 
when  localized  in  the  sigmoid  region  is  nearly  always  diagnosed  as 
the  result  of  carcinoma,  when  it  occurs  in  an  elderly  person  with  a 
history  of  constipation. 

Advanced  age,  recent  constipation,  cachexia,  and  blood  in  the 
stools  favor  cancer ;  while  long-standing  constipation,  absence  of  blood 
in  the  stools  after  repeated  examinations,  and  slight  cachexia  (or 
rather  loss  of  weight),  together  with  an  evidence  of  pus  formation, 
would  favor  peridiverticulitis. 

Entire  absence  of  constipation  may  occur  with  either,  and 
blood  has  been  found  in  one  diverticular  case.  Probably  many  of 
the  so-called  cases  of  cancer  are  really  this  condition. 

Perforative  Peritonitis. — In  these  cases  a  routine  examination  of 
the  sigmoid  should  be  made. 

Vesicocolic Fistida. — Probably  many  of  these  cases,  supposedly 
due  to  cancer  of  the  sigmoid,  are  the  result  of  diverticulitis  with 
adhesions  and  perforation  of  the  bladder.  Air  and  feces  pass  through 
the  urethra.  Cripps  found  45  cases  of  vesico-intestinal  fistula  out  of 
63  to  be  inflammatory,  onlv  9  cancerous,  and  some  of  these  doubtful. 

There  seems  to  be  a  liability  of  postoperative  peritonitis  follow- 

1  An  appendix  passing  transversely  to  the  left  iliac  fossa  can  sometimes  be 
determined  by  vaginal  or  rectal  examination.  An  alinormal  position  of  the  cecum 
occasionally  occurs.  With  tuberculosis,  V)acilli  may  lie  found  in  the  stools,  also 
pus  and  blood,  but  not  always  at  first.  The  tuberculin  reaction,  ocular  or  by  in- 
jection, aids  diagnosis.  Pus  and  blood  ayjpear  in  dysentery  and  syphilis,  and  the 
Ameba  or  Bacillus  dysenteriaMn  the  former  and  Wassermann's  reaction  in  the 
latter.  Mucus  alone  is  present  in  catarrh.  Actinomyces  are  found  in  the  stool 
in  actinomycosis.     Vaginal  examination  helps  diagnose  pelvic  conditions. 


634  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

ing  an  operation  for  diverticulitis,  probably  from  other  thin-walled 
diverticula. 

Diagnosis. — To  recapitulate:  Diverticulitis  occurs  usually  in 
persons  over  thirty-five  years  of  age  suffering  from  constipation  and 
of  obese  habit.  The  site  of  pain  about  corresponds  on  the  left  side 
to  that  of  appendicitis  on  the  right.  IMuscular  rigidity,  especially 
of  the  left  rectus,  is  present.  There  is  tenderness  on  pressure  in 
the  left  iliac  fossa.     Tumor  may  or  may  not  be  present. 

In  suppurative  cases  there  may  be  chills.  Leukocytosis  is  pres- 
ent. The  increase  in  the  polynuclears  and  hyperinosis  are  of  im- 
portance for  diagnosis. 

The  various  types  have  been  described ;  among  the  most  common 
are  acute  peritonitis,  resulting  from  perforation ;  local  abscess,  which 
may  break  into  some  viscus,  as  the  bladder,  or  which  must  be  opened ; 
acute  or  chronic  obstruction,  resulting  from  stenosis  of  the  sigmoid 
from  peridiverticulitis;  chronic  tumors,  simulating  carcinoma;  and 
milder  cases,  with  local  pain,  tenderness,  constipation;  and  a  local 
tumor,  which  symptoms  gradually  subside  under  treatment. 

Treatment. — ^The  acute  cases  should  receive  the  same  treatment 
as  acute  appendicitis.  In  mild  cases  the  bowel  should  be  emptied  by 
enema;  liquid  diet,  preferably  broths  and  gruels ;  ice-bag  continuously 
appHed;  absolute  rest  in  bed.  Subsequent  attention,  after  recovery, 
should  be  directed  to  the  careful  regulation  of  the  bowels  by  diet 
and  medication.  Intestinal  irrigation  and  high  olive  oil  injections 
also  are  of  value.  Cases  of  chronic  stenosis  may  be  temporarily 
treated  as  such.  Indications  for  operation  are  the  same  as  in  appen- 
dicitis. 

Acute  obstruction,  peritonitis,  and  abscess  require  immediate 
operation.  Chronic  obstruction  may  require  resection.  Appropriate 
operative  procedures  are  necessary  for  the  complications  described. 


CHAPTER   XXXI 

INTESTINAL    OBSTRUCTION— ACUTE   AND   CHRONIC. 

Intestinal  obstruction  occurs  in  two  types — acute  and  chronic. 
Acute  obstruction  is,  in  turn,  characterized  by  two  anatomic 
types : 

1.  Acute  intestinal  obstruction  with  sudden  complete  occlusion 
of  the  intestinal  lumen. 

2.  Acute  intestinal  obstruction  engrafted  suddenly  on  a  chronic 
obstruction  (chronic  stenosis),  due  to  a  sudden  blocking  of  the 
stenosed  intestines  from  various  causes,  such  as  by  a  foreign  body  or 
fecal  accumulation  above  the  stricture. 

ACUTE  INTESTINAL  OBSTRUCTION 

{Synonyms. — Ileus;  Miserere;  Passio  Iliaca.) 

General  Considerations. — Acute  intestinal  obstruction  may  be 
defined  as  a  sudden  acute  stoppage  of  the  passage  of  the  intestinal 
contents.  This  may  be  caused  by  mechanical  occlusion  of  the  intes- 
tinal canal  (mechanical  ileus) ,  by  a  sudden  loss  of  motor  power  in  a 
portion  or  in  all  the  bowel  (dynamic  or  paralytic  ileus) ,  or  by  a  com- 
bination of  these  conditions. 

•  Before  discussing  the  matter  further,  as  a  means  of  assistance  to 
diagnosis,  I  wish  to  call  a  few  very  important  facts  to  my  readers' 
attention. 

As  a  rule,  we  may  say  that  acute  obstruction  of  the  small  intes- 
tine gives  rise  to  more  severe  and  violent  symptoms  than  that  of  the 
large  intestine.  The  nervous  apparatus  of  the  small  intestine  is  in 
connection  with  most  important  plexuses,  the  solar  and  superior 
mesenteric,  and  the  pain  is  more  violent,  the  vomiting  earlier  and 
more  marked,  and  the  prostration  and  shock  more  rapid. 

The  early  appearance  of  indicanuria  and  of  anuria  are  also  sig- 
nificant of  obstruction  in  the  small  intestine. 

Moreover,  simple  occlusion  of  the  intestines  does  not  lead  to 
nearly  as  acute  symptoms  as  when  strangulation  is  present.  In  the 
latter  condition  interference  with  the  circulation  of  the  intestinal 
wall  and  of  the  mesentery  and  the  irritation  of  the  sensory  nerves 
give  rise  to  acute  and  violent  symptoms,  marked  pain,  vomiting, 
and  shock.  In  this  class  of  cases  we  have  the  acute  internal  hernias 
and  strangulations,  volvulus,  and  the  severe  type  of  acute  intussus- 
ception. Local  meteorism  is  generally  present  in  the  early  stages  of 
volvulus,  internal  herniaform  strangulation  and  kinking  of  the  bowels, 
and  enables  us  at  times  to  locate  the  character  of  the  lesion.     Often 

635 


636  DISEASES   OF   THE   STOMACH  AND   INTESTINES 

this  distention  rapidly  becomes  very  extensive,  as  in  volvulus,  for 
example,  a  general  distention  ensues,  so  that  determination  of  the 
condition  is  difficult. 

In  the  majority  of  cases  of  acute  obstruction  when  we  find  pres- 
ent marked  increased  peristaltic  movements  of  the  bowel,  with 
stiffening  and  rigidity  of  loops  of  intestines,  they  occur  in  acute 
cases  engrafted  on  cases  of  chronic  stenosis  with  hypertrophy  of  the 
bowel  muscle  above  the  stricture.  We  occasionally  see  this  symp- 
tom in  primary  acute  conditions,  especially  in  acute  intussusception. 

We  must  remember,  moreover,  that  acute  dilatation  of  the  stom- 
ach, either  alone  or  associated  with  intestinal  paresis,  quite  frequently 
occurs  after  operation,  and  presents  many  of  the  symptoms  of  acute 
dynamic  ileus.  There  is  obstruction,  in  fact,  in  many  cases  due  to 
pressure  of  the  organ  on  the  transverse  duodenum  or,  as  some  believe, 
by  mesenteric  traction.  The  stomach  may  occupy  the  left  half  or 
even  the  entire  abdominal  cavity.  I  have  referred  to  this  condition 
under  Acute  Dilatation  of  the  Stomach. 

Practically  we  may  say  that  in  every  case  of  acute  obstruction 
intra-abdominal  tension  is  markedly  increased,  thus  interfering  with 
the  physical  examination.  I  place  the  following  suggestions  at  the 
commencement  of  this  chapter  in  order  to  emphasize  them  the  more. 
They  are  of  value  as  an  aid  to  diagnosis  in  every  case  with  acute 
s5niiptoms : 

Immediate  and  thorough  lavage,  digital  examination  of  the  rec- 
tum, and  if  no  evidences  therein  of  obstruction  or  intussusception, 
preventing  the  entrance  of  an  injection,  then  a  careful  recurrent 
rectal  irrigation;  vaginal  examination  and  inspection  of  hernial 
openings  should  be  the  preliminaries  in  the  examination  of  every 
case.  Lavage  and  irrigation  of  the  bowel  immediately  promote  the 
comfort  of  the  patient  by  lessening  distention,  render  the  physical 
examination  easier,  and  the  combined  methods  are  an  invaluable 
aid  in  diagnosis.  It  may  be  necessary  to  substitute  a  high  enema 
for  irrigation. 

Etiology  of  Acute  Intestinal  Obstruction. — ^The  various  causes 
of  acute  intestinal  obstruction  on  account  of  their  importance  will 
now  be  considered  separately: 

The  first  classification  that  I  shall  describe  is  the  so-called  internal 
herniajorm  strangulation  of  the  bowel  (compression  of  the  intestines), 
due  to  strangulation  by  (a)  bands  and  adhesions,  the  result  of  a 
former  peritonitis;  (b)  Meckel's  diverticulum;  (c)  slits  and  apertures; 
(d)  incarceration  into  herniae ;  {e)  tumor  pressure  from  without. 

Frequency. — ^Fitz,  in  an  analysis  of  295  cases  of  acute  obstruction, 
gives  34  per  cent,  of  the  cases  as  due  to  this  type  of  strangulation 
(internal  herniaform),  excluding  volvulus;  35  per  cent,  out  of  1134 
cases  are  reported  by  Leichtenstern. 

Out  of  loi  cases  of  strangulation  Fitz  shows  that  63  were  due  to 
adhesions  and  bands,  and  21  to  vitelline  remains. 


INTESTINAL   OBSTRUCTION — ACUTE    AND   CHRONIC  637 

Strangulation  of  the  intestines  by  adhesions  and  bands  thus 
constitutes  the  largest  percentage  of  this  class.  In  some  cases  they 
may  be  congenital.  The  band  may  be  a  firm  fibrous  cord,  or  may 
be  tough  and  thin  as  a  thread,  occasionally  it  may  be  h  inch  wide. 

Strangulation  from  bands  and  adhesions  may  occur  in  four 
ways: 

1.  There  may  be  a  short  tense  band  firmly  attached  at  each  end, 
beneath  whose  arch  a  knuckle  of  the  intestines  passes,  the  space 
may  only  be  of  a  size  to  admit  two  to  three  fingers. 

2.  On  the  other  hand,  there  may  be  a  long  lax  band,  attached  at 
its  ends  and  forming  a  ring  or  spiral  8,  through  which  a  loop  of  the 
small  intestine  may  slip. 

3.  A  loop  of  intestines  filled  with  contents  may  lie  over  a  tense 
band  of  adhesions  and  thus  become  strangulated;  this  is  a  rare  oc- 
currence, but  has  been  described  by  Treves. 

4.  The  intestines  may  suddenly  become  kinked  and  occluded  by 
traction  from  an  adhesive  band,  as  if  an  ovarian  cyst  were  tapped 
and  the  sudden  contraction  drew  on  an  adhesion  to  the  intestines. 

These  bands  and  adhesions  may  occur  between  any  of  the  viscera, 
the  parietal  peritoneum,  omentum,  and  mesentery. 

Adhesions  may  surround  the  bowel  and  contract,  narrowing  its 
lumen,  also  a  mesenteric  contraction  may  be  a  cause. 

A  coil  may  be  caught  between  the  pedicle  of  a  tumor  and  the 
pelvic  wall  or  may  circumscribe  a  tumor  pedicle. 

Strangulation  by  MeckeVs  Diverticulum. — Meckel's  diverticulum 
is  due  to  the  incomplete  obliteration  of  the  vitelline  duct,  and  forms 
a  finger-like  projection  from  the  ileum,  usually  within  18  inches  from 
the  ileocecal  valve.  As  a  rule,  it  is  about  3  inches  long,  though 
frequently  longer,  and  cylindric  in  shape  with  a  conic  end,  though  the 
latter  is  occasionally  "clubbed."  The  end  may  become  attached 
to  the  abdominal  wall  near  the  navel,  to  the  mesentery,  or  to  some 
other  point,  and  thus  form  a  band  or  loop  under  which  strangula- 
tion may  occur.  More  often  the  diverticulum  is  free  and  may  form 
a  ring  into  which  its  end  projects.  A  loop  of  the  intestines  may  enter 
the  ring  and,  especially  if  the  tip  is  club  shaped,  may  push  it  before 
it  and  tie  a  knot  (Fig.  230). 

The  vermiform  appendix  may  become  adherent  to  some  point 
in  the  peritoneal  cavity  and  form  an  arch  under  which  a  loop  of  the 
intestines  may  become  strangulated.  This  may  likewise  occur  with 
the  P^allopian  tube. 

Strangulation  of  the  Bowel  Through  Slits  and  Apertures. — This 
type  is  less  often  met  with,  and  is,  in  fact,  quite  rare.  Slits  and 
apertures  in  the  mesentery  and  omentum  may  be  congenital,  but  are 
more  frequently  traumatic.  They  generally  occur  in  the  mesentery 
near  the  lower  part  of  the  ileum.  Fissures,  holes,  or  rings  are  more 
frequentlv  formed  by  peritoneal  adhesions;  more  rarely  strangula- 
tion may  occur  in  a  tear  of  the  uterus  or  bladder. 


638 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


Strangulation  from  Internal  Hernice. — These  are  situated  within 
the  abdominal  or  thoracic  cavity,  or  are  subperitoneal  or  retroperi- 
toneal, parallel  to  the  abdominal  wall  without  passing  outward. 

In  some  of  the  so-called  external  hernise  no  swelling  can  be  de- 
tected externally.  Moreover,  hernia  may  develop  in  an  accessory 
form  between  the  muscles  and  fascia. 

Among  internal  herniae  we  may  have  those  of  the  recessus  duode- 
nojejunalis,  intersigmoid  recess,  retroperitoneal,  anterior,  retrocecal, 
foramen  of  Winslow,  and  diaphragmatic. 


Fig.  230.— Knotting  of  a  Meckel's  diverticulum  which  has  a  button-like  swelling 
of  its  extremity  (after  Treves). 

Diaphragmatic  hernia  is  most  frequently  met  with  of  these  forms 
and  can  occasionally  be  diagnosed. 

It  may  be  congenital  or  traumatic  as  from  wounds,  contusions, 
or  excessive  vomiting. 

In  the  true  form,  a  hernial  sac  of  peritoneum  or  pleura  covers 
the  viscera ;  in  the  false  form  (the  more  frequent) ,  it  does  not.  This 
type  is  found  on  the  left  side,  the  stomach  being  involved  most  fre- 
quently, the  colon  and  small  intestine  less  so. 


INTESTINAL   OBSTRUCTION — ACUTE    AND    CHRONIC  639 

The  stomach  fundus  passes  into  the  thorax  and  apical  rotation 
occurs. 

Physical  Signs  of  Diaphragmatic  Hernia. — Pneumothorax,  less 
motility  of  the  side  of  thorax  involved,  bulging  of  the  walls  of  the 
thorax,  and  metallic  sounds  are  the  chief  symptoms.  Dyspnea,  dis- 
tress or  pain  in  the  thorax,  and  difficulty  in  swallowing  (dysphagia) 
may  be  present.  Diaphragmatic  hernia  can  be  diagnosed  by  inflation 
with  air  or  water,  the  use  of  the  x-ray,  or  gastrodiaphany. 

Mechanism  of  Internal  Herniaform  Strangulation  {Compression 
of  the  Intestines). — The  mechanism  of  the  type  of  obstruction  just 
described  is  as  follows : 

A  coil  of  gut  is  drawn  beneath  a  band  or  through  an  aperture, 
and  becomes  at  once  strangulated,  or  congestion  of  the  mesenteric 
vessel  occurs,  gas  and  pus  accumulate,  and  later  strangulation  occurs,' 
or,  in  addition,  a  torsion  of  the  bowel  may  take  place — necrosis, 
gangrene,  and  perforation  result. 

The  lower  part  of  the  ileum  is  chiefly  affected.  Peritonitis  may 
occur  early  (in  twenty-four  hours)  or  late  (in  one  to  two  weeks). 

Sex  and  Occurrence. — In  males  70  per  cent.,  though  some  claim 
occurrence  in  the  sexes  is  equal.  Between  twenty  and  forty  years 
cases  chiefly  occur,  though  40  per  cent,  are  between  fifteen  and  thirty 
years.  In  90  per  cent,  the  seat  of  the  trouble  is  in  the  small  intes- 
tine, usually  the  ileum;  in  67  per  cent,  strangulation  is  in  the  right 
iliac  fossa;  in  83  per  cent,  in  the  lower  abdomen  (Osier). 

Clinical  Symptoms. — These  are  characterized  by  their  sudden 
acute  onset  in  perfect  health.  Rarely  injury,  violent  movement, 
or  diarrhea  may  precede  the  attack,  and  are  considered  to  be  factors. 
Sudden  severe  pain,  occasionally  colicky,  often  severe  through- 
out, though  at  the  end  it  may  lessen.  The  pain  at  times  corre- 
sponds to  the  seat  of  the  strangulation.  Vomiting  begins  early  and 
is  persistent  and  soon  becomes  feculent;  absolute  constipation,  no 
flatus.  There  is  early  and  rapid  appearance  of  collapse,  urine  is 
scanty,  meteorism  slight  or  absent,  slight  tenderness  on  pressure,  no 
blood  in  bowel  movements  if  such  occur,  nor  is  it  discoverable  by 
enema.     Death  occurs  in  two  to  four  days. 

If  peritonitis  occurs,  meteorism  is  marked  and  pain  recurs  and  is 
severe.  A  circumscribed  area  of  dulness  or  tumor  is  rare.  The  attack 
is  of  a  fulminating  character. 

Volvulus  may  be  defined  as  an  obstruction  of  the  bowel  caused 
by  a  rotation  of  the  intestines  about  their  axis,  a  rotation  of  the  bowel 
about  its  mesentery,  or  an  intertwining  (rotation)  or  knotting  of  two 
intestinal  loops  with  their  mesenteries. 

It  occurs  most  frequently  in  the  sigmoid  flexure.  The  ascending 
colon,  cecum,  and  small  intestine,  especially  the  ileum,  may  some- 
times be  affected,  and  intertwining  of  the  intestines  is  most  often  met 
with  in  this  location. 

Mechanics. — The  Sigmoid  Flexure. — The  sigmoid  flexure  must  be 


640  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

large  and  its  mesocolon  long  and  narrow  for  the  development  of 
volvulus.  The  ends  of  the  sigmoid  are  thus  approximated,  and  it 
can  readily  rotate  around  the  mesocolon  as  a  pedicle.  This  condi- 
tion may  be  congenital  or  due  to  some  chronic  inflammation. 

Etiology. — Chronic  habitual  constipation  is  the  chief  cause,  as 
the  weight  of  the  fecal  matter  produces  local  displacement  and 
distorts  and  elongates  the  mesentery. 

The  rotation  is  usually  the  result  of  bodily  exertion.  On  the  other 
hand,  one  branch  of  the  flexure,  being  overdistended,  may  drop  down 
over  the  other.  The  branches  may  be  rotated  through  180  to  360 
degrees,  or  even  several  complete  rotations  may  occur.  The  dis- 
tention of  the  sigmoid,  the  congestion  and  exudation  of  fluid  and 
accumulation  of  gas  in  the  loop,  prevent  restitution  to  the  normal 
position.  The  accumulation  of  gas  in  the  colon  also  prevents  return 
to  normal. 

Small  Intestine. — The  same  conditions  favor  axial  rotation  of  the 
small  intestine. 

Inflammation  of  the  mesentery  is  sometimes  a  cause,  also  gall- 
stones, by  producing  colic  and  spasm. 

Accessory  Causes. — Leanness,  the  absence  of  fat  in  the  mesentery, 
and  hence  lessened  intra-abdominal  pressure  have  been  considered 
predisposing  causes,  also  trauma,  jumping  and  lifting,  sudden  diarrhea 
(peristalsis)  in  these  constipated  cases,  or  a  large  enema  (according 
to  some). 

Age. — It  is  more  common  in  older  than  in  young  subjects,  gener- 
ally in  those  over  forty  years  of  age,  though  Fitz  places  it  more 
frequently  at  thirty  to  forty  years  in  his  statistics. 

Frequency. — Fitz  finds  42  out  of  295  cases  of  acute  intestinal  ob- 
struction due  to  volvulus. 

Sex. — According  to  Fitz  it  is  more  frequent  in  men — 68  per 
cent.  Some  place  the  proportion  much  higher,  as  3  or  4  men  to 
I  woman. 

Symptoms. — This  condition  is  characterized  by  its  acuteness 
and  rapid  course.  It  is  more  rapid  than  any  other  form  except, 
possibly,  internal  strangulation  of  the  intestines. 

Pain  is  sudden,  violent,  and  never  absent,  and  sometimes  local- 
ized in  the  left  lower  quadrant;  it  may  remit,  but  never  a  complete 
intermission.  Vomiting  is,  as  a  rule,  violent  and  profuse,  continuous, 
and  is  an  early  symptom,  though  occasionally  less  frequent  in  sig- 
moid volvulus.  Fecal  vomiting  is  comparatively  rare.  Constipa- 
tion, both  for  feces  and  flatus,  occurs,  as  a  rule,  from  the  incipiency 
of  the  attack.  Occasionally  history  of  violent  exercise  or  of  acute 
diarrhea  may  precede  the  attack.  Tenesmus  may  be  present  in  vol- 
vulus of  the  sigmoid,  though  not  as  frequent  as  in  intussuscep- 
tion, and  in  rare  instances  there  is  the  passage  of  a  small  amount 
of  blood. 

Local  meteorism  is  an  important  symptom,  tlie  left  lower  portion 


INTESTINAL   OBSTRUCTION — ACUTE    AND    CHRONIC  64I 

of  the  abdomen  protrudes  as  a  tense  and  elastic  swelling,  feeling 
like  a  rubber  ball;  visible  peristaltic  movements  do  not  occur;  per- 
cussion may  be  tympanitic,  there  may  be  metallic  sounds  or,  rarely, 
dulness  if  much  edema.  In  some  cases  there  is  an  S-shaped  protru- 
sion of  the  abdomen,  most  prominent  in  the  upper  left  and  lower 
right  quadrant.  This  is  in  the  early  stages.  General  meteorism 
develops  most  rapidly,  next  in  rapidity  to  general  peritonitis ,  but  in  the 
latter  the  abdomen  is  very  tender;  while  in  the  former  it  is  only 
slightly  so.  Within  forty-eight  hours  the  abdomen  may  be  balloon 
shaped.     This  rapid  meteorism  is  an  aid  to  diagnosis. 

The  symptoms  are  very  acute  and  collapse  is  marked.  In  axial 
rotation  of  the  small  intestine  at  the  onset  there  may  not  be  absolute 
constipation ;  the  local  meteorism  starts  higher  up  and  there  is  no 
tenesmus.  In  these  cases,  curiously  enough,  the  symptoms  are  no 
more  violent  than  in  sigmoid  volvulus. 

Anatomy. — ^There  is  local  meteorism,  the  walls  of  the  distended 
loop  are  thickened,  rigid,  edematous,  and  dark  red.  The  peritoneal 
coat  is  often  torn,  as  is  the  muscularis.  Hemorrhages  are  seen  in  the 
intestinal  wall.  Blood,  gas,  mucus,  and  feces  lie  in  the  loop.  The 
mesentery  is  hyperemic  and  infiltrated.  The  twisted  part  of  the 
intestines  is  attenuated  and  pale.  Gangrene  may  occur  at  the 
line  of  demarcation.  Other  parts  of  the  intestines  are  collapsed  and 
pale  unless  general  meteorism  subsequently  occurs. 

Course. — The   course    of   volvulus    is 
always  acute.     The  patients  may  occa-  Reh<jrnm^^^_^^^^^J^s 

sionally  die  in  twelve  to  twenty-four 
hours  or  in  two  to  three  days;  the 
average  course  is  a  week.  They  die  of 
collapse,  exhaustion,  peritonitis,  or  from 
paralysis  of  the  heart  due  to  compres- 
sion from  tympanites.  Unless  operation 
is  performed  the  cases,  as  a  rule,  are 
fatal,  especially  those  with  complete  Fig.  231. — Intussusception. 
axial  rotation. 

Some  patients  who,  from  symptoms,  seem  to  have  suffered  from 
partial  rotation,  the  course  being  more  chronic,  have  recovered. 

Intussusception  ;  Invagination. — It  is  in  this  condition  that  one 
segment  of  the  intestines  slips  into  an  adjacent  segment,  so  that  the 
latter  forms  a  sheath  for  the  former.  The  two  portions  make  a  cylin- 
dric  tumor  which  varies  in  length  from  an  inch  to  many  feet.  The  con- 
dition is  always  a  descending  intussusception.  The  outer  tube  is  called 
the  sheath  or  intussuscipiens ;  the  middle  and  inner  tubes,  the  intussus- 
ceptum;  the  innermost  tube,  the  entering  tube;  the  middle  one,  the 
returning  tube  (Fig.  231).  The  upper  part,  where  the  middle  tube 
bends  over  into  the  sheath,  is  called  the  neck;  its  lower  part,  where 
the  inner  tube  bends  over  into  the  returning  cylinder,  is  called  the 
head.     Mucous  membrane  is  in  contact  with  mucous  membrane  and 

41 


642  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

peritoneum  with  peritoneum.  The  one  depicted  is  the  usual  form; 
sometimes  a  double  or  triple  invagination  may  occur,  or  an  incom- 
plete lateral  invagination;  the  reverse  of  a  diverticulum.  The 
mesentery  participates  in  the  invagination  and  becomes  compressed 
and  wedged  in  the  sheath.  The  serous  surfaces  may  become  ad- 
herent, so  that  the  invagination  cannot  be  disengaged.  There  are 
various  types  of  intussusception  which  may  occur  in  every  portion 
of  the  bowel : 

1 .  The  Ileocecal  Form.- — In  this  type  the  ileocecal  valve  forms  the 
apex  of  the  intussusception,  the  ilevun  the  internal  cylinder,  and  the 
colon  the  sheath;  this  often  forms  a  very  long  intussusception,  so 
that  the  valve  may  even  protrude  at  the  anus. 

2.  The  Ileocolic  Form. — The  lowest  part  of  the  ileum  forms  the 
apex  and  protrudes  into  a  cecum.  If  the  cylinders  become  adherent, 
then  the  ileocecal  valve  and  cecum  may  become  inverted. 

3.  Ileaca-ileocolic Form. — There  is  first  an  ileac  invagination  which 
may  force  the  intussuscepted  part  into  the  colon. 

There  may  also  be  intussusception  of  the  ileum,  jejunum  and 
ileum,  jejunum,  duodenum  and  jejunum,  duodenum,  colon,  colon 
and  rectum,  and,  rarely,  of  the  rectum. 

The  ileocecal  form  seems  to  predominate,  and  is  especially  fre- 
quent in  children. 

The  ileocolic  is  also  quite  frequent,  and  these  two  types  give  the 
longest  intussusceptions. 

In  adults  the  ileac  and  ileocecal  forms  occur  with  about  equal 
frequency,  and  in  the  colon  it  is  quite  frequent. 

Intussusception  of  the  vermiform  appendix  into  the  cecum 
has  been  reported,  •  and  also  of  the  ileum  into  the  open  Meckel's 
diverticulum,  when  this  is  patent  at  the  umbilicus,  and  also  by  the 
gut,  grasping  it  or  by  traction. 

The  mesentery  exerts  traction  on  the  intussusception  and  the 
bowel  curves  so  that  the  concavity  points  toward  the  mesenteric 
attachment.  This  may  cause  a  kinking,  which  further  closes  the 
intestinal  lumen.  Circulatory  changes  take  place  in  the  intussuscep- 
tion, edema,  swelling,  etc.,  and  in  severe  cases  strangulation  and 
gangrene.  The  intussusception  may  slough  off.  Peritonitis  is 
first  noted  on  the  second  or  third  day;  it  may  be  local  or  become 
general. 

Mechanism  of  Intussusception. — The  probable  reason  of  intus- 
susception being  so  frequent  in  young  children  is  that  during  the 
early  months  of  the  infant's  life  there  is  a  rapidly  increasing  dispro- 
portion between  the  transverse  diameters  of  the  large  and  small 
intestines,  the  large  intestine  increasing  very  rapidly  in  diameter,  so 
chat  the  ileum  can  readily  prolapse.  For  the  production  of  invagina- 
tion there  is  probably  a  local  spasm  of  a  portion  of  the  intestines 
and  the  normal  gut  below  is  pulled  upward  by  its  longitudinal 
fibers  over  the  contracted  piece  of  bowel,  and  the  irritation  caused 


INTESTINAL   OBSTRUCTION — ACUTE    AND    CHRONIC  643 

by  the  invaginated  part  then  causes  spasmodic  contraction  of  the 
gut  above,  which  carries  the  incarceration  further  downward. 

Numerous  experiments  have  been  carried  out  for  a  study  of  the 
mechanism.  None  of  these  seem  to  show  that  primary  paralysis  is 
a  factor,  but  that  the  condition  is  rather  of  a  spasmodic  type. 

Paralysis  of  a  limited  part  of  the  bowel  may,  I  believe,  be  a  factor 
in  some  cases. 

Frequency. — ^Weiss  finds  that  out  of  321  cases — 

Per  cent.                 Per  cent.  Per  cent.  Per  cent. 
In  the  newborn  and  suck- 
lings  Iliac,  24  Ileocecal,  42  Ileocolic,  10       Colic,  24 

Childhood  to  puberty Iliac,  23  Ileocecal,  43  Ileocolic,  14       Colic,  26 

Adult Iliac,  29.5  Ileocecal,  34.5  Ileocolic,  4.5   Colic,  27 

Meckel's  diverticulum  (adult).  4.5 

177  in  first  year;  85,  two  to  fourteen  years;  59,  later  age. 

The  agonal  type  of  intussusception  occurs  just  before  death,  is 
of  no  importance,  and  is  often  multiple.  Of  Leichtenstern's  cases,  131 
out  of  543  occurred  in  first  year,  80  of  them  in  four  to  six  months. 

Age. — Most  frequent  in  infancy  and  early  childhood,  up  to  the 
fifth  year. 

Causes. — Diarrhea,  intestinal  polypi,  carcinoma  and  stricture, 
ingestion  of  irritating  food,  contusion  of  the  abdomen,  shaking 
the  body,  and  acute  and  chronic  diseases  have  been  given  as 
factors. 

Benign  tumors  when  present,  such  as  fibroma,  myoma,  especially 
the  polypoid  form,  are  generally  at  the  apex  of  the  intussusception, 
and  most  frequently  occur  in  the  ileum.  They  may  set  up  peris- 
talsis, and  constriction  and  invagination  so  result. 

It  is  rare  with  carcinoma  or  stenosis,  and  it  may  occur  when  the 
tumor  is  pedunculated.     Often  the  cause  is  not  discoverable. 

Symptoms. — In  the  acute  cases  the  attack  is  characterized  by 
its  suddenness.  There  may  be  preUminary  intestinal  disturbances, 
such  as  diarrhea  or  colicky  pains.  Often  they  appear  while  the 
patient  is  quiet,  asleep  or  nursing.  I  shall  refer  to  the  acute  cases 
only  in  this  chapter.  The  iliac  and  ileocecal  forms  are  the  most 
acute.     The  colic  and  rectal  form  are  more  gradual. 

Pain. — There  is  first  pain  of  a  violent  colicky  character,  at  times 
arising  at  a  definite  point.  It  may  be  very  severe  and  overwhelm 
the  patient,  and  in  children  may  cause  convulsions,  or  they  may 
scream  and  groan.  It  is  continuous  at  first,  later  may  intermit, 
though  at  times  it  may  be  continuous  throughout.  In  some  cases 
the  pain  is  in  the  right  iliac  region,  or  occasionally  at  the  umbilicus, 
and  at  times  local  tenderness  is  present.  Spasms  and  contraction 
with  rigidity  of  loops  of  intestines  sometimes  occur  in  acute  cases, 
but  more  usually  in  the  chronic.  Vomiting  is  constant  and  early 
in  children,  is  not  constant  in  adults,  and  hence  a  less  important 
symptom  in  them. 


644  DISEASES    OE   THE    STOMACH   AND   INTESTINES 

The  vomiting  depends  on  the  position  of  the  intussusception; 
the  lower  down  it  is,  the  less  likely  the  vomiting  at  the  outset;  peri- 
tonitis brings  it  on. 

Feculent  movements  may  occur  at  first;  later,  diarrhea  with 
blood  and  mucus,  and  tenesmus  if  the  invagination  is  low  down. 
In  some  cases  this  is  quite  marked;  hemorrhages  from  the  bowels 
ensue,  even  if  the  invagination  is  high  up. 

Fecal  vomiting  is  rare.  Vomitus  usually  contains  gastric  con- 
tents, mucus,  and  bile,  and  only  occurs  in  one-fourth  of  the  cases 
in  adults.  The  higher  up  the  invagination,  the  sooner  it  appears. 
Meteorism  of  a  great  degree  is  exceptionally  present;  sometimes 
the  abdomen  is  even  retracted.  It  is  dependent  on  the  degree  of 
constriction. 

Tumor. — A  palpable  tumor  can  at  times  be  appreciated  in  about 
one-half  the  cases.  It  varies  in  size,  may  seem  shorter  to  the  touch 
than  it  really  is,  or  it  may  impart  the  feel  of  a  double  swelling;  it  is 
usually  of  a  cylindric  or  sausage  shape,  elongated,  and  curved.  Its 
consistency  may  vary  at  different  times  and  it  can  be  slightly  com- 
pressed. It  may  feel  hard  and  then  suddenly  soft,  or  even  vanish. 
The  changes  in  consistency  and  resistance  are  due  to  the  spasmodic 
contraction  in  the  intestinal  wall.  During  contraction  it  may  be 
tender. 

Situation. — Most  frequently  the  tumor  is  located  in  the  region  of 
the  sigmoid;  then  at  the  anus  or  rectum,  then  at  the  cecum,  descend- 
ing transverse  or  ascending  colon. 

The  position  of  the  tumor  may  be  permanent  if  there  are  any 
adhesions,  or  it  may  change  if  the  intussusception  increases. 

Prolapse  of  the  swelling  through  the  anus  often  occurs. 

Duration. — Especially  in  children  severe  symptoms  of  collapse 
may  take  place  within  two  to  three  days,  and  if  vomiting  persists, 
it  may  be  feculent. 

About  80  per  cent,  of  young  subjects  die ;  subacute  cases  run  two 
to  four  weeks  and  spontaneous  cures  occur  in  this  type. 

Death  from  collapse,  gangrene,  and  peritonitis  may  occur  during 
the  first  week  in  infants,  or  in  two  to  three  weeks  in  adults.  Sepsis 
and  phlebitis  may  be  associated. 

Diagnosis. — Acute  commencement,  vomiting  constant  in  children, 
but  not  so  in  adults;  at  times  tenesmus,  the  presence  of  bloody 
stools;  then  retention  of  feces  and  flatus,  distention  of  the  abdomen 
usually  slight ;  and  last  the  appearance  of  a  tumor  are  diagnostic  of 
intussusception. 

Obturation  of  the  intestines  signifies  the  occlusion  of  the  bowels 
by  a  foreign  body  situated  therein ;  among  such  are  gall-stones, 
enteroliths,  foreign  bodies  which  have  been  swallowed  or,  rarely, 
inserted  into  the  rectum,  and  masses  of  fecal  matter. 

Gall-stones,  in  exceptional  cases  if  very  large,  may  cause  an  acute 
intestinal  obstruction.     They  probably  have  ulcerated  through  into 


INTESTINAL    OBSTRUCTION ACUTE    AND    CHRONIC  645 

the  bowel  from  the  gall-bladder.  They  may  become  impacted  in  the 
duodenum,  jejunum,  or  at  the  ileocecal  valve. 

Cases  of  this  last  type  are  more  frequent  in  women  than  in  men. 
In  many  there  is  a  previous  history  pointing  to  cholelithiasis.  The 
symptoms  are  pain,  violent  vomiting  (generally  bilious) ,  which  fre- 
quently becomes  feculent,  constipation,  which  is  not  alwavs  absolute, 
meteorism,  often  not  pronounced,  and  collapse.  In  some  cases  a 
hard  resistant  swelling  may  be  felt.  In  others  there  will  be  some 
flatus  from  the  rectum.  Milder  symptoms  of  occlusion  may  occur, 
evidently  when  the  lumen  of  the  bowel  is  not  completely  shut  off. 
The  patient  in  this  class  of  cases  would  suffer  from  attacks  of  colicky 
pain,  vomiting,  and  constipation,  but  no  collapse.  These  cases  may 
also  have  perforative  peritonitis,  and  often  die  on  the  fifth  to  tenth 
day  unless  operated  on.  At  times  the  stone  may  move  onward  and 
escape,  with  recovery  of  the  patient. 

Occasionally  there  will  be  some  diarrhea  with  blood  during  the 
onward  movement  of  the  calculus,  the  result  of  traumatism  to  the 
mucosa. 

Enteroliths. — An  intestinal  calculus  rarely  causes  acute  ob- 
struction unless  it  has  been  dislodged  from  an  intestinal  diverticulum, 
and  suddenly  occludes  the  bowel.  It  generally  produces  the  symp- 
toms of  chronic  obstruction  or  digestive  disturbances  and  obstinate 
constipation. 

Calculi  ordinarily  consist  of  carbonates  or  phosphates  with  a 
foreign  body  as  a.  nucleus ;  or  as  a  result  of  the  prolonged  use  of  drugs, 
such  as  chalk,  bismuth,  magnesia  or  salol,  or  some  indigestible 
material,  such  as  oat-stones  from  oatmeal,  etc.,  in  which  inorganic 
salts  are  deposited.     They  frequently  develop  in  the  large  intestine. 

Foreign  Bodies. — These  are  accidentally  or  intentionally  swal- 
lowed. This  is  especially  apt  to  occur  with  children  or  with  insane 
or  hysteric  persons.  Occlusion  has  also  been  produced  by  the  in- 
sertion of  a  foreign  body  into  the  rectum.  Among  such  substances 
are  knives,  spoons,  forks,  keys,  marbles,  stones,  false  teeth,  fruit 
stones,  neckties,  hair  or  beads,  pins  and  needles;  in  fact,  all  varie- 
ties of  objects.  In  some  cases  the  symptoms  may  first  be  chronic, 
when  suddenly  acute  occlusion  will  occur;  in  others  it  is  acute  from 
its  incipiency.  Murphy's  button  has  caused  occlusion,  also  a  large 
mass  of  tapeworms.  Pedunculated  tumors  of  the  intestinal  wall, 
such  as  polypi,  fibroma,  and  myoma,  may  produce  it. 

Many  of  these  objects  can  be  readily  recognized  by  means  of  the 
rt-rays  and  the  fluoroscope,  or  by  a  Rontgen  picture. 

Fecal  masses  may  completely  occlude  the  intestines  as  a  result  of 
habitual  constipation.  The  symptoms  are  usually  subacute  or 
chronic  at  first,  and  finally  become  acute  from  complete  occlusion. 

Dynamic  Ileus  (Intestinal  Paresis). — Acute  obstruction  pro- 
duced by  paralysis  of  the  bowels  is  called  paralytic  or  dynamic  ileus. 
Among  the  various  causes  are  hydrocele,  contusion  or  inflammation 


646  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

of  the  testicles,  etc.,  which  may  cause  a  reflex  paresis;  paracentesis 
of  ascites ;  trauma  over  the  abdomen ;  after  laparotomy  from  manipu- 
lation of  the  viscera  or  following  removal  of  a  large  tumor,  or  after 
Cesarean  section ;  other  operations  from  the  effect  of  the  anesthetic ; 
damage  to  the  intestines,  as  from  a  hernia  after  relief  of  the  stran- 
gulation ;  local  or  general  peritonitis ;  renal  or  biliarj^  colic  may  cause 
reflex  obstruction,  possibly  due  to  spasm  or  paresis;  overdistention 
of  the  intestines  from  gas  or  feces ;  various  toxemias,  as  from  typhoid 
or  pneumonia  or  from  any  acute  infection,  also  sepsis,  as  from  ap- 
pendicitis, and  as  a  concomitant  of  shock  or  uremia. 

Congenital  Causes. — Congenital  occlusion  of  the  rectum  or  colon 
produces  acute  obstruction. 

Acute  Obstruction  Engrafted  on  Chronic  Obstruction. — Chronic 
stenosis  with  chronic  constipation  may  suddenly  produce  an  acute 
obstruction. 

Pathology  of  Acute  Obstruction. — In  acute  obstruction  the 
pathologic  findings  differ  somewhat,  according  to  the  various  types 
and  factors.  There  has  been  an  unfortunate  tendency  to  confuse 
the  findings  in  acute  and  chronic  obstruction.  If  we  have  an  acute 
condition  engrafted  on  a  chronic  obstruction,  we  may  then  find 
above  the  point  of  obstruction  dilatation  and  hypertrophy  of  the 
intestines,  catarrh,  and  ulcerations. 

In  true  acute  occlusion  the  process  is  too  rapid  for  these  changes, 
but  the  following  occur :  the  intestines  below  the  occlusion  are  empty 
and  contracted ;  above  it  the  intestines  are  markedly  dilated  and  dis- 
tended and  the  walls  are  thinner.  If  a  loop  is  im^olved,  the  walls 
are  thick  and  congested  (but  not  hypertrophied) .  The  coils  above 
the  obstruction  are  distended,  filled  with  gas  and  ill-smelling  contents. 
If  the  small  intestine  is  occluded  the  distention  will  involve  the  gastro- 
intestinal tract  above  the  occlusion ;  if  the  large  intestine  is  occluded 
the  colon  will  be  distended  first ;  later  regurgitation  through  the  ileo- 
cecal valve  occurs  and  universal  distention. 

In  a  loop  which  is  strangulated  there  is  local  meteorism  and  it 
ma}^  be  markedly  distended ;  there  are  congestion,  edema,  hemorrhage, 
a  dark  red  color  of  the  gut  and  gangrene,  with  general  peritonitis  and 
bloody  fluid  in  the  cavity ;  or  a  single  perforation  from  ulceration  or 
gangrene  may  occur;  and  rarely,  if  the  case  be  prolonged,  a  local 
abscess  or  local  peritonitis. 

General  Symptoms  of  Acute  Obstruction. — As  a  rule  these  begin 
very  acutelv,  though  rarely  there  is  a  previous  history  of  diarrhea  or 
constipation,  improper  food,  a  laxative,  traumatism,  or  of  violent 
exertion. 

There  are  at  first  violent  abdominal  pains,  colicky  in  type,  local 
or  dift'use.  The  pain  is  continuous,  though  sometimes  it  may  remit. 
Nausea,  hiccough,  and  vomiting  first  of  the  gastric  contents,  later 
bilious,  and,  finally,  feculent  vomiting  rapidly  follow.  Meteorism 
quickly  appears;  there  is  absolute  constipation  and  no  passage  of 


INTESTINAL    OBSTRUCTION — ACUTE    AND    CHRONIC  647 

flatus.  Tympanites  increases,  a  great  increase  of  intra-abdominal 
pressure  is  present,  and  the  muscles  become  tense  and  the  entire 
abdomen  tympanitic;  respiration  is  markedly  interfered  with,  the 
breathing  is  rapid  and  shallow,  pulse  rapid  and  feeble,  extremities 
cold,  cold  sweat,  face  pale, 'eyes  sunken,  and  extreme  thirst;  total 
collapse  and  the  patient  rapidly  succumbs. 

Only  a  brief  analysis  will  be  made  of  these  symptoms,  as  they  have 
been  thoroughly  described  under  the  respective  causes  of  acute  ob- 
struction. Pain  is  the  most  constant  symptom  and  it  never  remits 
completely.  As  a  rule,  it  is  more  acute  in  obstruction  of  the  small 
intestine ;  the  initial  pain  is  probably  due  to  irritation  of  the  intestines 
and  peritoneum,  later  to  spasmodic  intestinal  contraction,  and  finally 
to  peritonitis.  In  the  last  stage  pain  may  cease  as  a  result  of  the 
terminal  fatal  intestinal  paresis.  External  pressure,  as  a  rule,  in- 
creases the  pain. 

Active  and  visible  peristaltic  movements  and  tetanic  stiffening  of 
the  bowel  are  exceptionally  seen  in  acute  occlusion,  when  the  intes- 
tines were  previously  healthy  and  unobstructed;  and  if  they  are  visible, 
are  never  as  marked  as  in  cases  of  acute  obstruction  supervening  on 
a  chronic  stenosis  of  the  intestine.  This  is  an  important  point  to  re- 
member. The  visible  peristaltic  movements  if  present,  in  connec- 
tion with  the  other  symptoms,  are  an  aid  to  diagnosis. 

Vomiting  is  nearly  always  present.  At  first  it  is  probably  due  to 
reflex  irritation  of  the  nervous  system;  later  it  has  been  ascribed  to 
antiperistalsis ;  or  to  mechanical  causes,  as  explained  by  Haguenot, 
who  states  that  fluid  contents  accumulate  above  the  obstruction; 
and  from  gas  pressure  and  contraction  of  the  abdominal  muscles  the 
contents  are  forced  into  the  areas  of  less  resistance  and  thus  reach  the 
stomach,  where  they  cause  vomiting. 

Feculent  vomiting  often  occurs  when  the  obstruction  is  in  the 
small  intestine,  due  to  putrefactive  processes  therein. 

Constipation  is  usually  marked;  though  rarely  there  is  diarrhea 
with  blood,  as  in  intussusception. 

Absence  of  flatus  is  quite  significant. 

Meteorism. — This  may  first  be  circumscribed  (local),  there  being 
tympanites  and  protrusion  of  the  intestines  for  a  short  distance 
above  the  point  of  obstruction ;  thus,  a  protrusion  of  the  right  side 
would  first  be  noted  if  an  obstruction  occurs  at  the  hepatic  flexure. 
Later  the  meteorism  becomes  general  and  the  abdomen  barrel  shaped. 

Collapse. — This  is  marked,  especially  so  if  there  is  strangulation, 
and  it  is  more  rapid  if  the  small  intestine  is  involved. 

Thirst  and  dryness  of  the  tongue  are  present,  being  due  to 
vomiting,  sweating,  and  increased  intestinal  secretion,  which  di- 
minish the  fluidity  of  the  blood. 

Coma,  delirium,  and  fever  rarely  occur. 

Diagnosis  of  Acute  Intestinal  Obstruction. — Having  described 
the  symptoms  of  acute  obstruction,  a  careful  study  of  the  physical 


648  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

signs  and  the  methods  of  physical  examination  are  necessary  to  com- 
plete the  diagnosis. 

Investigation  of  the  type  and  degree  of  meteorism  (tympanites), 
both  by  inspection  and  percussion,  is  of  great  importance.  At  this 
point  I  again  desire  to  call  to  my  reader's  attention  that  acute  dila- 
tation of  the  stomach  presents  many  symptoms  of  ileus  and  may 
obscure  the  diagnosis.  The  pain  of  acute  ectasia  is  not  as  severe 
and  continuous  as  with  acute  intestinal  obstruction,  in  that  it  is  im- 
mediately relieved  by  lavage.  The  stomach  may  occupy  the  entire 
abdominal  cavity,  though  usually  it  fills  the  left  half  and  lower  part 
of  the  abdomen.  The  vomiting  of  acute  ectasy  is  also  peculiar,  in 
that  it  is  very  profuse,  incessant,  and  in  large  amount,  and  comes 
up  in  gulps  without  straining.  It  is  usually  watery  and  greenish  in 
hue,  though  it  may  be  brownish  or  black.  If  the  stomach  alone  is 
involved,  distention  will  disappear  after  lavage. 

Inspection. — If  there  be  occlusion  of  the  jejunum  or  duodenum, 
unless  the  stomach  also  be  greatly  dilated,  the  upper  part  of  the  ab- 
domen is  protruded  slightly. 

Occlusion  at  the  cecum  or  lower  ileum  gives  the  so-called  "ladder" 
pattern,  the  coils  lying  one  above  another  either  obliquely  or  trans- 
versely in  the  abdomen,  and  the  distention  is  more  central. 

In  stenosis  of  the  sigmoid  flexure  the  upper  and  lateral  aspects 
of  the  abdomen  are  usually  distended,  and  we  have  so-called  flank 
meteorism. 

When  the  distention  is  limited  to  a  section  of  the  colon,  flank 
meteorism  may  be  unilateral;  thus  the  right  iliac  region  is  intensely 
tympanitic  if  the  occlusion  involves  the  hepatic  flexure.  If  the  small 
intestine  alone  be  included,  the  distended  loops  are  seen  in  the  center 
and  flank  meteorism  is  absent. 

With  volvulus  the  left  lower  portion  of  the  abdomen  protrudes; 
or  an  S-shaped  protrusion  of  the  abdomen,  most  prominent  at  the 
upper  left  and  lower  right  quadrants,  occurs. 

We  must  remember  that  local  meteorism  occurs  only  early,  and 
later  general  t^^mpanites  ensues,  so  that  we  may  not  see  the  case 
early  enough  to  avail  ourselves  of  these  data. 

Peristaltic  waves,  if  present,  aid  to  locate  the  obstruction. 

Palpation. — In  some  cases  palpation  reveals  a  circumscribed  area 
which  is  tender  on  pressure,  and  may  aid  in  localizing  the  obstruction. 
In  others  a  tumor  is  palpable,  especially  with  intussusception,  occlu- 
sion by  tumors,  or  fecal  impaction. 

Palpation  of  the  hernial  openings  is  necessary.  Digital  examina- 
tion of  the  rectum  and  vagina  are  most  important.  We  may  feel  a 
stricture  or  intussusception  in  the  rectum  and  bloody  fluid  may 
escape.  I  deprecate  the  method  of  inserting  the  hand  in  the 
rectum. 

Percussion. — Local  meteorism  gives  a  deep  and  loud  note  which 
is  not  truly  tympanitic,  but  often  of  a  metallic  ring,  and  helps  locate 


INTESTINAL    OBSTRUCTION — ACUTE)    AND    CHRONIC  649 

the  obstruction.  Exceptionally  dull  percussion  may  be  heard  over 
the  swelling,  due  to  edema  of  the  intestinal  walls  or  to  accumulation 
of  fecal  contents  or  blood  admixture. 

In  normal  subjects  the  percussion  note  in  the  upper  lumbar  region 
behind  is  high,  flat,  and  dull.  It  is  loud  and  deep  in  stenosis  of  the 
large  intestine.  When  the  obstruction  is  in  the  sigmoid,  the  loud  and 
deep  note  is  found  on  both  sides,  and  when  in  the  splenic  flexure  or 
transverse  colon,  then  only  in  the  upper  lumbar  region  of  the  right 
side. 

If  there  is  general  tympanites  and  no  change  of  percussion  is 
noted  for  a  long  time  over  any  one  region  of  the  abdomen,  there  is 
probably  intestinal  paresis.  General  tympanites,  with  absence  or 
diminution  of  liver  dulness,  does  not  always  mean  perforation  of 
the  bowel,  though  it  frequently  does  so.  One  can  often  determine 
peritoneal  exudation  by  percussion. 

Auscultation. — Splashing  and  gurgling  noises  often  demonstrate 
that  peristalsis  is  marked.  Succussion  sounds  and  fluctuation  on 
palpation  are  frequently  found  in  the  intestines  above  the  point  of 
stenosis.  Examination  of  the  vomited  matter  will  show  whether 
fecal  material  is  present.  Urine  is  scanty  and  albuminous,  and  often 
shows  indican  and  gives  Rosenbach's  reaction,  especially  in  obstruc- 
tion of  the  small  intestine.  Suppression  of  urine  occurs  in  this 
condition. 

Differential  Diagnosis  Between  Obstruction  of  the  Small 
and  Large  Intestine. —  Obstruction  of  Small  Intestine. — Pain,  vomit- 
ing, and  collapse  are  more  acute  and  appear  early.  Earl)^  feculent 
vomiting.  Indicanuria  early,  on  second  or  third  day.  Anuria  early, 
early  meteorism,  and  often  is  high  up.  Absence  of  early  indicanuria 
(excluding  peritonitis  and  intestinal  inflammation)  tends  to  show 
obstruction  is  not  in  the  small  intestine. 

Vomiting  in  duodenal  obstruction  is  rarely  feculent,  but  is  so 
if  obstruction  is  lower  down. 

Obstruction  of  Large  Intestine. — If  the  disease  is  chronic  or  runs 
a  long  course,  absence  of  indican  shows  lesion  is  present  in  the  large 
intestine;  its  presence,  however,  tells  nothing,  as  it  may  appear  late. 

General  symptoms  are  usually  less  violent,  though  they  are  vio- 
lent in  volvulus.  Fecal  vomiting  occurs  later.  Meteorism  is  lower 
down  in  the  early  stage  of  acute  obstruction. 

Tenesmus  and  blood  in  the  stool  suggest  an  obstruction  low  down. 
Brinton's  method  by  the  injection  of  water  is  sometimes  of  service. 
If  not  more  than  i  quart  can  be  injected,  the  obstruction  is  probably 
low  down;  if  2  quarts,  it  is  probably  above  the  sigmoid,  and  if  4 
quarts,  then  in  the  commencement  of  the  colon  or  higher  up. 

Inflating  the  bowel  with  CC\,  by  Rose's  bottle  or  by  air  will  fill 
the  large  intestine  up  to  the  obstruction.  This  method  is  of  no  service 
if  there  is  very  marked  distention,  and  lavage  should  be  first  per- 
formed to  reduce  it. 


630  DISEASES    OF   THK    STOMACH   AND   INTESTINES 

Differential  Diagnosis  Between  the  Different  Forms  of  Acute 
Obstruction. — This  is  often  difficult.  In  some  cases  it  is  possible, 
but  in  others  we  can  only  conjecture  the  probable  type. 

Acute  strangulation  in  hernise,  omental  slits,  or  by  bands  consti- 
tutes about  34  per  cent,  of  cases.  This  is  more  frequent  in  males 
between  twenty  and  forty  years.  In  90  per  cent,  the  small  intes- 
tine is  the  seat  of  trouble,  mostly  in  the  ileum  and  lower  abdomen  or 
right  iliac  fossa.  The  symptoms  are  sudden  and  acute.  There  may 
have  been  a  previous  history  of  peritonitis,  hernia,  or  injury.  Pains 
are  severe,  vomiting  begins  early  and  soon  becomes  feculent,  abso- 
lute constipation  and  no  passage  of  flatus.  Tenesmus  absent.  Col- 
lapse is  early  and  marked.  Urine  is  scanty  and  meteorism  slight. 
Attack  is  of  fulminating  type.  Physical  examination  often  gives  no 
definite  data. 

Volvulus. — This  most  frequently  involves  the  sigmoid.  History 
frequently  of  chronic  constipation  is  more  common  in  males  and  in 
those  over  forty  years  of  age,  from  forty  to  sixty,  though  Fitz's  sta- 
tistics show  frequency  from  thirty  to  forty  years  of  age.  If  volvulus 
of  small  intestine,  it  cannot  be  differentiated  from  incarceration.  Pain 
is  sudden  and  violent,  it  ma}^  remit,  but  never  intermits.  Vomiting 
is  quite  common,  but  may  be  absent  at  first  in  volvulus  of  the  sig- 
moid, and  in  the  latter  case  fecal  vomiting  may  not  be  present.  It 
occurs  in  some  cases,  but  is  not  as  frequent  as  in  internal  strangula- 
tion; in  fact,  it  is  rather  rare.  j\Ieteorism  occurs  early  and  is  at  first 
local  in  the  lower  left  quadrant,  or  as  an  S-shaped  protrusion.  General 
meteorism  rapidly  occurs,  and  thus  is  an  aid  to  diagnosis.  The  sig- 
moid can  occasionally  be  felt  as  a  tumor.  Constipation  and  absence 
of  flatus  are  usually  complete ;  occasionally  there  is  a  little  blood  in 
the  stool  and  only  a  moderate  amount  of  water  can  be  injected  into 
the  rectum.     Symptoms  are  acute  and  collapse  is  marked. 

Intussusception. — IMost  frequent  in  infancy  and  early  childhood. 
Onset  is  sudden.  Pains  appear  early,  are  colicky  in  character;  in 
children,  may  cause  them  to  scream  or  have  convulsions;  pains  are 
paroxvsmal.  Vomiting  occurs  early  and  constantly  in  children;  a 
less  important  s3^mptom  in  adults. 

Invaginated  coil  can  be  appreciated  or  a  tumor  in  about  one-half 
the  cases.    Occasionally  the  swelling  may  prolapse  through  the  anus. 

Tenesmus  and  evactiation  of  blood  occur,  then  constipation  and 
retention  of  flatus.  Fecal  vomiting  rare,  unless. case  is  prolonged ;  col- 
lapse is  early  in  children  (in  two  to  three  days),  but  not  as  early  as  in 
strangulation ;  collapse  is  slower  in  adults. 

Obstrtiction  by  Gall-stones,  Enteroliths,  and  Foreign  Bodies. — 
Occlusion  from  gall-stones  occurs  chiefly  in  older  women.  There  is 
at  times  a  previous  history  of  gall-stones,  jaundice,  and  liver  enlarge- 
ment, or  tenderness,  which  aids  our  diagnosis.  The  obstruction 
usually  occurs  in  the  small  intestine.  The  general  symptoms  are 
often  not  so  severe  as  in  other  types,  there  being  some  flatus  passed 


INTESTINAL    OBSTRUCTION — ACUTE    AND    CHRONIC  65 1 

at  times  and  in  some  cases  slight  diarrhea  with  blood.  If  obstruction 
of  the  ileum,  feculent  vomiting  is  more  marked.  Meteorism  is  not  so 
marked  and  collapse  not  so  great.  Occasionally  the  stone  can  be 
palpated. 

Enteroliths. — Their  recognition  is  quite  difficult  unless  small 
fragments  have  been  voided.  They  develop  most  frequently  in  the 
large  intestine.  Symptoms  of  chronic  obstruction  or  digestive  dis- 
turbances and  obstinate  constipation  are  more  frequent.  Acute  s}-mp- 
toms  are  more  rare. 

Foreign  Bodies. — The  previous  history  and  use  of  the  x-rays  will 
determine  these.  Obstruction  from  accumulation  of  pits  will  generally 
be  suspected  by  reason  of  the  appearance  of  some  of  them  in  the  stool. 

Fecal  Accumulation. — This  rarely  gi\'es  the  picture  of  acute  ob- 
struction unless  a  tumor  or  stricture  of  the  intestine  be  present,  when 
accumulation  may  suddenly  cause  complete  occlusion.  Rectal 
examination  usually  shows  hardened  scybalae  and  palpation  demon- 
strates a  hardened  mass  in  the  colon  (descending  sigmoid  or  cecum 
especially).  If  the  mass  be  softer,  it  will  impart  a  doughy  feel  on 
pressure. 

Dynamic  Ileus. — Acute  gastroduodenal  dilatation  of  the  stomach 
presents  symptoms  of  intestinal  obstruction,  and  commences  with 
acute  pain,  undoubtedly  due  to  stenosis  of  the  duodenum  by  pres- 
sure. Under  Diagnosis  of  Acute  Obstruction  I  have  described  the 
pecuhar  type  of  vomiting  in  acute  ectasy  and  also  the  position  of 
the  stomach.  The  pain,  distention,  and  other  symptoms  are  relieved 
by  frequent  lavage  and  by  the  adoption  of  the  abdominal  position 
(the  patient  Mng  on  his  belly). 

Obstruction  of  the  bowel  from  a  paralytic  condition  in\'olves,  as 
a  rule,  a  considerable  segment,  or  frequently  the  entire  tract.  After 
reduction  of  a  hernia  probably  only  a  small  segment  is  first  involved, 
but  I  believe  paralysis  of  a  considerable  segment,  and  in  many  cases 
of  the  entire  bowel,  finally  results.  The  acute  cramp-like  pains,  per- 
sistent and  paroxysmal,  are  absent  in  this  type  of  obstruction  (really 
not  a  true  obstruction  at  all),  which  always  occur  in  the  early  stages 
of  other  types  of  obstruction.  When  acute  spasmodic  pain  is  present 
and  persistent,  I  always  feel  positive  of  a  true  obstruction.  The  vom- 
iting, constipation,  collapse,  etc.,  may  be  similar  to  obstructive  ileus. 
There  may  be  sudden  pain  with  the  acute  distention,  so  that  per- 
foration is  suspected,  but  after  lavage  and  enteroclysis  the  pain  dis- 
appears, and  muscular  rigidity  is  found  to  be  absent.  These  feat- 
ures exclude,  first,  "obstructive  ileus,"  on  account  of  disappearance 
of  the  pain;  and  second,  "peritonitis."  In  the  early  stages  of  "dy- 
namic ileus,"  distention,  interference  with  the  cardiorespiratory  func- 
tions, and  obstinate  constipation  precede  the  vomiting  and  severe 
syptoms  as  a  rule.  There  is  usually  more  of  a  sense  of  painful  dis- 
comfort and  oppression,  except  in  the  cases  of  sudden  acute  disten- 
tion. 


652  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

In  the  terminal  stages  of  true  obstruction,  paresis  of  the  bowel 
may  occur,  and  then  spasmodic  pain  disappears;  in  paresis  of  the 
bowel  from  peritonitis  there  is  the  general  pain  and  tenderness  from 
the  peritonitis,  but  not  the  acute  spasmodic  pain  peculiar  to  true 
obstruction. 

In  true  dynamic  ileus,  therefore,  there  is  the  absence  of  that 
acute  persistent  spasmodic  pain  of  severe  type  which  is  present  in  all 
cases  of  true  obstruction. 

Differential  Diagnosis  Between  Intestinal  Obstruction  and 
Other  Diseases. — Acute  Peritonitis. — Generally  a  history  of  local 
peritonitis,  such  as  appendicitis  with  pain  localizing  in  right  iliac 
fossa,  and  then  sudden  cessation  of  the  cramp-like  pains,  followed 
by  abdominal  tenderness,  muscular  rigidity,  great  distention,  and 
frequently  rise  of  temperature.  Vomiting  generally  begins  later  and 
feculent  vomiting  still  later,  etc. 

In  obstruction  the  character  of  pain  is  more  severe  and  persistent, 
as  a  rule,  and  often  in  the  umbilical  region  or  in  the  left  lower  quadrant ; 
temperature  is  subnormal  at  the  start;  abdominal  tenderness  is  not 
as  marked;  feculent  vomiting  earlier;  often  local  meteorism  before 
general  tympanites.  General  pains  are  colicky  and  persistent  until 
peritonitis  and  paresis  set  in.  The  paralytic  form  of  ileus  may  often 
occur  with  infectious  diseases,  or  acute  appendicitis  with  peritonitis 
(general),  also  after  operation  or  inflammation  in  the  pelvis  or  genito- 
urinary organs ;  and  the  knowledge  of  these  facts  aid  our  diagnosis. 
We  must  remember  that  in  hysteric  women  all  the  symptoms  of 
ileus,  even  to  fecal  vomiting,  may  occur  without  there  being  any 
obstruction. 

With  biliary  and  renal  colic  there  may  be  a  reflex  paralytic  ileus, 
but  the  symptoms  of  these  conditions  aid  the  diagnosis. 

lycad-  and  arsenic-poisoning  have  sometimes  been  mistaken  for 
ileus,  but  again  we  have  the  history  and  other  symptoms,  especially 
of  enteritis.  Simple  intestinal  colic  soon  subsides  under  treatment. 
Acute  pancreatitis  and  enteritis  give  their  symptoms. 

There  is  tenderness  in  the  course  of  the  pancreas  if  this  is  involved, 
a  circumscribed  epigastric  swelling,  and  tender  spots  throughout  the 
abdomen  (Fitz) ;  but  in  some  cases  it  is  difficult  to  differentiate 
pancreatitis  from  obstruction. 

Course. — The  course  of  acute  obstruction  depends  upon  its  cause 
and  site.  The  higher  up  in  the  intestine,  the  more  acute  the  course, 
as  a  rule. 

Volvulus  and  strangulation  are  very  acute.  The  patient  rm.^' 
die  in  collapse  within  a  few  hours,  or  the  course  may  be  prolonged 
to  two  to  three  days  or  even  a  week.  Intussusception,  if  unoper- 
ated,  may  last  several  weeks.  If  the  patient  survives  the  collapse, 
and  the  patency  of  the  gut  becomes  reestablished  (as  in  intussus- 
ception, foreign  bodies,  or  volvulus),  flatus  is  first  passed  and  then 
later  a  fecal  movement,  and  the  symptoms  gradually  abate.     The 


INTESTINAL   OBSTRUCTION — ACUTE    AND    CHRONIC  653 

invaginated  bowel  has  been  known  to  slough  off  and  be  passed  in  the 
stool.  From  changes  in  the  gut,  due  to  ulcers,  adhesions,  etc.,  the 
patient  may  subsequently  develop  symptoms  of  chronic  obstruction. 

If  operation  is  not  performed,  the  patient  usually  dies  of  acute 
shock  or  peritonitis.  The  latter  may  be  due  to  perforation  or  to  direct 
penetration  of  the  paralyzed  wall  of  the  gut  by  intestinal  bacteria. 

In  some  there  may  be  a  circumscribed  peritonitis.  With  the 
diffuse  peritonitis  we  have  the  symptoms  already  described. 

Embolic  processes  may  develop  in  the  liver,  lungs,  and  other 
organs.  There  may  be  aspiration  pneumonia  or,  exceptionally, 
local  abscess,  with  perforation  of  the  abdominal  wall,  or  into  another 
part  of  the  intestines  or  into  other  viscera,  as  into  the  stomach,  blad- 
der, vagina,  or  uterus. 

Prognosis. — The  prognosis  of  acute  obstruction  is  very  serious. 
Some  observers  state  that  about  one-third  of  all  cases  recover, 
however. 

Obstruction  caused  by  coprostasis,  gall-stones,  or  some  foreign 
body  give  the  best  prognosis.  Dynamic  ileus  with  modern  methods 
of  treatment,  I  believe,  is  next  in  regard  to  favorable  results,  then 
intussusception,  and  the  worst  cases  are  volvulus  and  strangulation. 
The  earlier  the  operation,  the  better  the  prognosis.  The  last  types  I 
believe  fatal  nearly  invariably,  unless  early  operation  is  carried  out. 

Treatment. — ^This  may  be  divided  into  medical  and  surgical,  and 
the  respective  indications  are  extremely  clear.  I  shall  first  briefly 
classify  these,  giving  the  treatment  in  tabulated  form. 

Cases  for  Medical  Treatment. — i.  Acute  obstruction  due  to  fecal 
accumulation.  Acute  attacks  are  rare;  they  are,  rather,  sicbacute 
or  acute  engrafted  on  chronic : 

(a)  I^avage  is  indicated  to  relieve  tympanites,  if  present,  or  if 
vomiting. 

(b)  Digital  examination  of  the  rectum  and  removal  of  scybalae 
with  the  fingers,  and  then  frequent  enemata  of  soapsuds,  olive  oil, 
glycerin,  or  ovj  (200  cc.)  of  magnesium  sulphate  (saturated  solution) 
in  water,  i  pint  (500  cc),  followed  by  recurrent  enteroclysis  with 
normal  saline  solution  at  110°  to  120°  F.,  using  2  to  3  gallons  at  a 
sitting,  about  h  to  i  pint  (250-500  cc.)  being  kept  in  the  bowel, 
h'or  the  first  twenty-four  to  forty-eight  hours  the  treatment  consists 
in  the  simple  mechanical  emptying  of  the  rectum  and  large  intestine. 
The  enemata  should  contain  about  i  to  2  quarts  (liters),  in  which 
is  olive  oil,  i  pint  (500  cc),  alone  or  with  glycerin,  oiv  (125  cc). 
It  is  well  to  give  the  enema  with  the  patient  in  the  knee-chest  posi- 
tion, the  buttocks  elevated  as  high  as  possible.  If  vorhiting  or  dis- 
tention, no  food  at  all  until  this  ceases;  thirst  may  be  relieved  by 
moistening  the  mouth,  sucking  a  piece  of  lemon  or  orange,  and,  if 
necessary,  by  hypodermoclysis,  rectal  saline  enemata,  or  proctocly- 
sis. Milk  is  objectionable,  as  it  forms  curds  and  helps  fill  the  bowels. 
Broths  and  soups  should  be  given  until  the  accumulation  has  been 


654  DISEASES    OF   T5E    STOMACH   AND   INTESTINES 

removed.^  Strychnin  by  hypodermic,  gr.  eV  to  3^1  (0.00108-0.002 1) 
three  or  four  times  a  day,  can  be  given  as  a  stimulant.  It  also  helps 
tone  up  the  bowel.  Tincture  of  belladonna  in  large  doses,  admin- 
istered up  to  physiologic  symptoms,  liTLx  (0.59)  three  or  four  times  a 
day,  is  of  service,  as  soon  as  it  can  be  retained.  Later,  olive  oil,  oij 
to  iv  (60.0-125.0),  can  be  given  several  times  a  day  by  mouth.  On 
the  second  or  third  day,  if  matters  are  progressing  favorably,  give 
cathartics,  calomel,  castor  oil,  etc.,  by  mouth.  Massage  and  external 
electricity  are  of  value  in  these  cases  after  the  acute  symptoms  have 
subsided.  I  have  frequently  employed  electric  enteroclysis.  I  have 
seen  it  take  several  weeks  to  completely  empty  the  bowel. 

2.  The  second  class  of  cases  in  which  medical  treatment  is  indi- 
cated is  in  dynamic  ileus.     The  indications  are: 

(a)  Abolition  of  food. 

(b)  Relief  of  thirst,  as  previously  indicated. 

(c)  Frequent  lavage  to  relieve  intra-abdominal  tension  and  also 
vomiting. 

(d)  Frequent  enteroclysis  (recurrent)  with  hot  normal  saline  solu- 
tion at  115°  to  120°  F.,  several  gallons  being  used,  a  small  part  being 
kept  in  the  intestines  (preferably).  High  enemata  with  soapsuds,  olive 
oil,  and  glycerin  are  also  of  service. 

(e)  Electric  enteroclysis. 

If)  Tincture  of  belladonna,  Ttlx  (0.59),  given  three  or  four  times  a 
day  up  to  physiologic  symptoms.  Strychnin,  gr.  -gV  (0.002),  every 
three  hours. 

(g)  Magnesium  sulphate  (saturated  solution)  by  rectum,  oiv 
(125.0).  Heat  locally  is  of  value,  and  in  one  case  the  continuous 
local  application  of  the  ice-bag  stimulated  the  bowels  to  contract.  I 
prefer  the  ice-bag  in  many  cases,  unless  collapse  is  present. 

Cathartics  by  mouth  immediately  after  lavage,  especially  cal- 
omel, gr.  V  (0.3),  crushed  up  in  water  and  poured  in  through  the 
stomach-tube  at  the  end  of  the  washing.  Plain  water  and  no  saline 
solution  should  be  employed  for  lavage  when  calomel  is  administered. 
Physostigmin  sulphate,  gr.  y^o  to  eV  (0.0006-0.001),  every  two  to  three 
hours  for  three  doses.  If  all  methods  fail  and  the  patient  is  rapidly 
losing  ground,  then  simple  enterostomy  of  the  most  distended  loop, 
under  cocain,  as  suggested  by  Elsberg  in  obstructive  ileus,  I  believe, 
is  indicated.  This  procedure  allows  the  escape  of  gas  and  some  con- 
traction of  the  intestines  to  take  place.  Magnesium  sulphate  solu- 
tion should  be  injected  through  the  opening,  and  the  procedures 
already  suggested  should  be  continued.  Drainage  should  be  closed 
after  twenty-four  hours.  In  my  own  experience  I  have  had  good 
results  from  continuous  and  active  medical  treatment.  The  lavage 
followed  by  catharsis  by  mouth  is  of  equal  importance  as  the  entero- 
clysis.    Proctoclysis  is  not  sufficiently  active. 

1  This  only  refers  to  after  the  subsidence  of  acute  symptoms  and  after  the 
bowels  have  acted.     No  food  is  given  before  this  time. 


INTESTINAL   OBSTRUCTION^ACUTE    AND    CHRONIC  655 

Obstruction  by  Foreign  Bodies.— li  the  obstruction  is  by  accumu- 
lation of  fruit  stones,  an  enterolith,  or  a  gall-stone,  and  the  case  is 
seen  on  the  first  day  of  attack,  lavage  and  the  administration  of 
§iv  (125  cc.)  of  olive  oil  through  the  stomach-tube  aids  to  lubricate 
its  passage,  followed  by  enteroclysis.  No  cathartic  should  be  given  by 
mouth.  If  the  mass  begins  to  come  away  and  symptoms  are  relieved 
at  once,  then  delay;  otherwise,  operate. 

If  the  case  is  seen  later,  with  progressive  symptoms,  use  lavage 
and  enteroclysis  to  reHeve  distention  and  operate  at  once. 

Intussusception. — With  infants  or  young  children  the  stomach 
should  first  be  washed  out  to  reHeve  abdominal  tension.  An  anes- 
thetic is  then  administered  and  the  child  placed  in  the  Trendelen- 
burg position,  and  an  attempt  at  reduction  may  then  be  made  by 
inflation.  A  bellows  is  attached  to  a  catheter,  and  the  air  should 
be  injected  slowly,  the  buttocks  being  held  together.  The  best  guide 
to  the  amount  introduced  is  the  tension  of  the  abdominal  walls ;  if 
tension  is  marked  some  air  is  allowed  to  escape. 

This  procedure  should  not  occupy  over  fifteen  to  twenty  minutes. 
A  saline  solution,  milk  and  water,  or  thin  gruel  at  a  temperature 
of  100°  to  105°  F.,  for  the  relaxing  effect  can  be  employed  instead 
(as  suggested  by  Holt).  The  fluid  is  suspended  in  a  fountain  syringe 
4  or  5  feet  above  the  patient's  head,  the  tension  of  the  abdomen 
being  watched.     Otherwise  the  procedure  is  the  same. 

Reduction  is  indicated  by  a  rumbling  sound  and  by  the  abdomen 
resuming  its  natural  contour,  with  disappearance  of  the  tumor ;  in 
some  cases  a  gush  of  feces  follows. 

If  these  symptoms  are  absent,  the  abdomen  is  examined  while  the 
patient  is  still  under  chloroform,  especially  the  right  iliac  fossa,  for 
the  continued  presence  of  the  tumor. 

It  is  better  not  to  repeat  the  injection. 

If  the  tumor  is  present,  or  if  vomiting  continues  and  no  gas  or 
feces  are  expelled,  or  the  pulse  and  temperature  rise,  immediate 
operation  is  indicated. 

This  method  of  taxis  should  be  tried  on  the  young  in  an  early 
stage  (the  first  day) ;  if  later,  operate.  If,  on  the  other  hand,  there 
is  immediate  improvement,  small  doses  of  opium  are  given  for  a  few 
days  to  prevent  re-invagination. 

Surgery.— In  all  other  cases  of  acute  intestinal  obstruction  ex- 
cept those  noted,  early,  preferably  immediate,  operation  is  indicated. 

A  large  percentage  of  fatalities  imputed  to  operation  are  due  to 
delay  on  the  part  of  the  physician;  thus,  in  strangulation,  volvulus, 
intussusception,  and  obstruction  from  foreign  bodies  (except  under 
the  condition  of  the  rapid  passage  of  foreign  bodies,  as  noted  above), 
immediate  operation  is  indicated.  The  earlier  the  operation  the  bet- 
ter the  prognosis. 

In  these  cases  cathartics  should  never  be  given,  the  bowel  should 
not  be  massaged,  nor  electricity  used. 


656  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Puncture  of  the  bowel  through  the  abdominal  wall  to  relieve  gas  is 
absolutely  dangerous — an  invitation  to  peritonitis. 

Laxatives  do  positive  harm.  The  attempted  diagnosis  of  the  seat 
of  the  acute  obstruction  by  the  administration  of  bismuth  by  mouth 
and  the  use  of  x-rays,  which  necessitate  a  delay  of  twenty-four  hours, 
should  never  be  undertaken.^ 

Lavage  (frequent)  is  of  first  importance ;  it  lessens  intra-abdominal 
tension  and  also  the  pain,  makes  diagnosis  easier,  and  in  some 
cases  has  actually  proved  curative.  This  last  is  explained  by  the 
fact  that  the  gastro-intestinal  distention  is  reHeved  above  the  point 
of  obstruction,  and  occasionally  the  gut  escapes  from  the  constriction. 

If  the  patient  is  seen  on  the  first  day  of  the  attack  lavage  should 
be  given  at  least  twice,  one  or  two  hours  apart,  while  preparing  for 
operation ;  if  later,  then  once  before  operation. 

Enteroclysis  at  115°  to  120°  F.  is  of  value  to  lessen  the  distention 
due  to  general  paresis  and  improve  the  pulse ;  if  the  intussusception 
lies  in  the  rectum,  the  latter  is  contra-indicated. 

No  .fluid  or  ice  by  mouth,  but  the  tongue  can  be  moistened  and 
small  normal  saline  injections  or  proctoclysis  be  administered  for 
thirst.  These  methods  also  relieve  postoperative  thirst.  Heat  or 
cold  to  abdomen.     Hypodermoclysis  and  infusion  if  there  is  shock. 

Lavage  often  relieves  the  pain,  but  if  this  is  very  severe,  morphin, 
gr.  I  (0.016),  by  hypodermic,  and  repeat  to  lessen  shock.  All  these 
methods  are  of  use  while  preparing  for  immediate  operation. 

The  general  medical  methods  of  opium  or  morphin  for  three  or 
four  davs  and  expectant  treatment,  with  subsequent  operative  fatal- 
ity, are  to  be  deplored. 

Operate  in  acute  peritonitis.  Subseqeunt  to  operation,  lavage, 
if  vomiting,  and  nutritive  enemata ;  no  food  or  water  by  mouth ;  later, 
a  little  hot  water.  Open  bowels  by  enema  or  enteroclysis  in  twenty- 
four  to  forty-eight  hours,  as  intestinal  paresis  is  usually  present; 
earlier  if  the  symptoms  persist  which  are  due  to  this  condition. 

Rectal  injection  of  400  cc.  (oxij)  of  7  to  8  per  cent,  salt  solution  in 
intussusception  to  produce  reversed  peristalsis  has  been  suggested  by 
Riegel.  Experimentally  it  has  proved  efficacious,  but  practically  I 
am  dubious  of  its  value,  as  most  cases  of  intussusception  are  adhe- 
rent or  strangulated. 

In  desperate  cases  enterostomy  with  drainage  of  the  intestines, 
done  under  local  anethesia  (cocain) ,  is  advisable.  A  few  hours  later 
(within  twenty-four  hours)  radical  operation  with  relief  of  the  ob- 
struction can  be  performed.  Elsberg-  holds  that  preliminary  enter- 
ostomy, leaving  the  prolonged  search  for  the  obstruction  for  a  second 
operation,  to  be  more  frequently  advisable. 

1  Bismuth  enema,  followed  by  the  .r-rays,  is  only  of  use  in  determining  obstruc- 
tion in  the  large  intestine.  It  is  of  value  in  chronic  cases,  but  not  advisable  in 
acute  ones. 

2  The  Value  of  Enterostomy  and  Conservative  Operative  Methods  in  the  Sur- 
gical Treatment  of  Acute  Intestinal  Obstruction,  Annals  of  Surgery,  May,  1908. 


INTESTINAL   OBSTRUCTION — ACUTE    AND    CHRONIC  657 

CHRONIC   INTESTINAL   OBSTRUCTION 

In  this  condition  there  is  a  stenosis  or  narrowing  of  the  lumen 
of  the  intestines,  but  the  obstruction  is  not  acute  and  complete  in  the 
earlier  stages,  but  comes  on  gradually. 

Etiology. — It  may  be  caused  by  the  same  factors  which  pro- 
duce acute  obstruction,  if  the  entire  lumen  of  the  canal  is  not 
occluded. 

One  of  the  most  frequent  causes  of  chronic  obstruction  is  stric- 
ture resulting  from  ulcers  or  new  growths.  The  latter,  even  if  they 
do  not  occupy  the  entire  canal,  may  protrude  at  one  point  and 
partially  occlude  the  intestines.  They  may  be  benign  or  malig- 
nant. 

In  addition  we  have  the  peculiar  tumor-like  tuberculosis  of  the 
cecum,  which  causes  a  progressive  stenosis,  and  chronic  peridivertic- 
ulitis (sigmoiditis)  may  produce  a  narrowing  of  the  lumen  with  symp- 
toms.    Both  of  the  latter  conditions  often  simulate  carcinoma. 

Strictures  resulting  from  ulcers  involve  the  large  intestine  much 
more  frequently  than  the  small,  probably  in  a  ratio  of  6  to  i ,  accord- 
ing to  Treves. 

Among  the  causes  of  stricture  are  tubercular,  stercoral,  syphilitic, 
typhoid,  dysenteric,  and  duodenal  ulceration. 

Woodward^  has  demonstrated  that  dysenteric  ulcers  rarely  cause 
intestinal  stricture,  and  Nothnagel  agrees  with  him.  Stercoral 
and  tubercular  ulcers  are  a  quite  frequent  cause,  as  is  also  syphilitic 
ulceration.     Typhoid  ulcers  are  a  rare  cause. 

There  are  other  rare  factors  reported,  such  as  ulceration  in  a  por- 
tion of  the  bowel  that  has  been  incarcerated,  or  stricture  following 
the  sloughing  off  of  invaginated  intestines.  A  few  cases  of  trauma- 
tism with  damage  to  the  intestines  and  subsequent  stricture,  or  of  a 
circumscribed  peritonitis  following  trauma,  and  subsequent  stenosis 
have  been  reported.  Carcinoma  of  the  pancreas,  enlargement  of  the 
retroperitoneal  glands,  and  gall-stones  may  cause  stricture.  A 
stricture  may  be  congenital. 

Rectal  strictures  are  quite  frequent,  and  much  more  so  in  women, 
as  from  syphilitic,  tubercular,  stercoral,  and  hemorrhoidal  ulcers. 
Operation  for  prolapse  of  rectum  or  for  hemorrhoids,  especially  the 
Whitehead  operation,  traumatism  from  the  syringe-tip,  or  the  intro- 
duction of  foreign  bodies  may  produce  stricture. 

Traumatism  from  the  child's  head  during  parturition  may  be  a 
cause. 

Gonorrheal  abscess  of  the  Bartholin  glands  may  lead  to  ulcera- 
tion of  the  rectum  and  stricture  ultimately  result. 

Anatomy  of  Chronic  Stenosis  of  the  Intestines. — The  intestines 
below  the  stenotic  area  are  empty  and  contracted  and  the  bowel 
normal.     Above  the  point  of  stenosis  the  bowel  is  dilated,  often  to 
1  Medical  and  Surgical  History  of  the  War  of  the  Rebellion. 
42 


658  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

a  great   degree,  and   may  form   a   sac-like   pouch.     The  dilatation 
may  involve  only  a  short  part  of  the  bowel  above  the  stenosis. 

In  some  cases  there  is  considerable  distention  from  gas  and  the 
abdomen  may  assume  the  barrel  shape.  The  degree  of  distention 
depends  on  the  tightness  of  the  stricture.  There  is  stagnation  of  the 
intestinal  contents  above  the  stricture,  which  causes  mechanical  dis- 
tention and  may  stimulate  the  peristaltic  action.  This  material 
also  acts  as  an  irritant.  When  the  musculature  is  stimulated  to  in- 
creased activity  hypertrophy  is  thus  produced.  This  accounts  for 
the  violent  visible  peristaltic  movements  in  chronic  obstruction. 

Patel  claims  that  in  stenosis  from  external  pressure  we  have 
dilatation  without  hypertrophy,  and  that  the  latter  only  occurs  if 
ulcers,  which  cause  contraction  through  irritation,  are  present.  This 
would  explain  the  occurrence  of  hypertrophy  without  stenosis  in 
some  cases  of  intestinal  ulceration. 

Changes  in  the  mucosa  and  submucosa  are  frequently  present, 
a  catarrhal  condition  and  ulceration  (stercoral).  General  peritoni- 
tis, local  peritonitis,  or  local  abscess  may  result. 

The  intestines  may  become  elongated  above  the  stenosis. 

Location  of  Stenosis. — The  large  intestine  is  the  most  common  seat 
of  the  stricture.  Syphilitic,  dysenteric,  and  stercoral  strictures  are 
chiefly  localized  here,  as  are  also  those  resulting  from  traumatism  or 
from  follicular  ulceration. 

Tuberculous  ulceration  produces  stricture  most  commonly  in 
the  small  intestine,  though  tuberculous  tumor  is  found  in  the  cecum, 
and  probably  tuberculous  ulcer  is  more  frequent  in  the  rectum  than 
has  been  usually  credited.      Tuberculosis  of  the  sigmoid  also  occurs. 

Malignant  strictures  are  most  frequent  in  the  large  intestine. 

If  the  ulcer  producing  the  stricture  lies  parallel  to  the  longitudinal 
axis  of  the  bowel,  stenosis  is  not  as  marked  as  when  it  is  an  annular 
ulcer  (girdle  ulcer).  The  stricture,  as  a  rule,  is  short  and  the  ex- 
ternal aspect  of  the  intestine  looks  as  if  a  ribbon  had  been  tied  about 
it.  The  external  surface  of  the  gut  is  often  covered  with  exudate, 
so  that  the  bowel  is  thickened  and  there  may  be  adhesions  between 
the  intestines  and  other  loops  or  other  viscera,  which  further  con- 
strict the  intestines. 

The  stricture  consists  of  cicatricial  tissue  unless  malignant. 
Folds  of  mucous  membrane  near  the  cicatrix  or  hypertrophic  poly- 
poid protrusion  of  mucous  membrane  may  aid  in  closing  the  gut. 

If  there  are  numerous  stenoses,  as  from  tubercular  ulcers,  there 
may  be  sacculated  dilatation  of  the  small  intestine  between  the 
stenosed  points. 

Symptoms. — These  depend  upon  the  cause  of  the  obstruction; 
malignant  growth  must  be  differentiated  clinically  from  benign  con- 
ditions.    The  symptoms  generally  come  on  gradually. 

In  stenosis  of  the  small  intestine  the}^  may  be  latent  for  a  con- 
siderable time,  on  account  of  the  fluidity  of  the  bowel  contents,  and 


INTESTINAL   OBSTRUCTION — ACUTE    AND    CHRONIC  659 

then  appear  with  rapidity.  On  the  other  hand,  stenosis  of  the  colon 
produces  symptoms  more  rapidly  on  account  of  the  solid  contents. 

As  a  rule,  constipation  is  one  of  the  earliest  symptoms,  and  this 
gradually  becomes  worse.  The  patient  complains  of  digestive  dis- 
turbances and  swelling  of  the  abdomen,  there  is  loss  of  appetite,  and 
nausea.  Stenotic  feces  in  round  balls,  cylinder  (pipe-stem)  or  tape- 
like movements,  -are  suggestive,  but  not  conclusive.  This  type  of 
feces  may  occur  in  spastic  constipation,  and,  on  the  other  hand,  the 
feces  may  be  normal  in  form  with  a  stricture  high  up.  Diarrhea  at 
times  alternates  with  constipation.  The  diarrheal  movements  may 
be  extremely  offensive  and  contain  mucus,  or  even  pus  and  blood ;  this 
last  is  especially  true  in  malignant  stenosis,  where  there  are  active 
ulcerations,  or  in  intussusception.  The  diarrhea  often  relieves  the 
patient.  We  must  remember  that  chronic  diarrhea  is  present  in 
some  cases  when  there  is  a  marked  catarrh  above  the  stricture,  and 
this  will  sometimes  lead  one  astray.  Severe  pain  of  a  colicky  type 
occurs  in  all  cases,  and  this  may  at  times  be  excruciating;  it  may 
be  localized  near  the  seat  of  stricture,  but  in  other  cases  be  more 
diffuse,  radiating  even  toward  the  thorax  and  producing  a  feeling 
of  oppression  and  dyspnea.  A  symptom  which  occurs  with  the 
colic,  which  can  be  considered  pathognomonic,  is  the  visible  peris- 
taltic movement  of  the  intestines^ ,  in  which  the  loops  can  be  seen  to 
stiffen  and  relax  alternately.     The  coils  appear  and  disappear. 

Vomiting  may  not  occur  at  first,  but  is  later  more  frequent,  and 
if  finally  the  obstruction  becomes  complete,  may  be  marked  and 
even  feculent.     Gurgling,  rolling  sounds,  and  meteorism  are  present. 

Location  of  the  Obstruction. — This  influences  the  character 
of  the  symptoms.  If  the  stenosis  is  situated  above  Vater's  papilla, 
the  symptoms  are  similar  to  those  of  stenosis  of  the  pylorus.  IMarked 
dilatation  of  the  stomach,  nausea,  and  vomiting  are  prominent. 
R.  T.  Morris  has  demonstrated  that  in  some  cases  of  spider  adhesions 
from  the  gall-bladder  there  may  be  severe  hemorrhage  and  pain 
which  may  simulate  gastric  ulcer.  There  is  usually  a  history  of 
previous  gall-bladder  disease.  If  the  obstruction  lies  below  Vater's 
papilla,  we  again  have  gastric  dilatation,  but  frequent  bilious  vomiting.- 

The  lower  down  the  obstruction,  the  less  pronounced  the  gastric 
symptoms,  as  a  rule,  and  the  more  marked  the  constipation  and 
colicky  pains.     There  may  even  be  an  absence  of  gastric  s>-mptoms 

1  Peristaltic  unrest  (intestinal)  is  not  always  present,  especially  in  the  earlier 
stages  of  the  disease;  and  at  times,  late  in  the  condition,  the  bowel  may  become 
fatigued  and  paretic  from  overdistention.  Often,  however,  the  peristaltic  move- 
ments will  aid  in  locating  the  position  of  the  obstruction. 

2  The  stomach  contents  are  neutral  or  alkaline,  due  to  regurgitation  of  ]ian- 
creatic  juice  and  bile,  and  duodenal  digestion  takes  place  witliin  the  stomach. 
With  stenosis  alaove  the  papilla,  gastric  contents,  as  in  benign  ])yl()ric  stenosis, 
are  acid.  Riegel  states  another  sign  of  duodenal  stenosis  is,  that  when  the 
stomach  has  been  emi)lied  the  night  l^efore,  twelve  hours  later  as  nuich  as  3 
liters  (quarts)  can  be  frequently  aspirated.  The  reaction  and  contents  differ 
from  that  of  gastrosuccorrhea. 


66o  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

for  a  considerable  period  if  the  stenosis  be  in  the  lower  ileum  or  in 
the  colon.  The  symptoms,  however,  are  always  more  severe  in 
chronic  intussusception  or  chronic  types  of  strangulation  than  in 
ordinary  cicatricial  stenosis. 

X-Rays.^ — The  administration  of  bismuth  by  mouth  and  inspec- 
tion the  following  day  with  the  fluoroscope  or  by  photography  may 
demonstrate  the  location  of  the  stenosis.  If  it  be  apparently  in  the 
large  intestine  a  few  days  later,  it  has  been  suggested  that  a  high 
injection  of  bismuth  and  olive  oil  be  given,  and  the  examination  be 
repeated  as  a  check  test.  These  procedures  are  not  to  be  recom- 
mended in  acute  cases. 

Inspection  of  the  Abdomen. — When  the  stenosis  is  high  up  in 
the  small  intestine  there  is  apt  to  be  distention  of  the  epigastric 
region,  and  when  in  the  low^er  part  of  the  small  intestine  or  in  the 
large  intestine,  then  there  is  considerable  abdominal  distention. 

The  active  peristaltic  contraction  of  the  intestines  is  marked, 
the  coils  (stiffened)  rising  and  falling,  and  often  performing  winding 
or  vermicular  motions.  These  movements  are  associated  with  col- 
icky pains  and  with  gurgling  and  rolHng  noises. 

Sausage-shaped  ridges  may  appear  with  depressions  in  their 
vicinity,  and  in  a  few  seconds  the  ridges  disappear  in  one  part  and 
appear  in  another,  the  coils  never  remaining  visible  in  one  place  for 
any  length  of  time.  They  appear  hard  and  stiff  to  the  hand  and  then 
suddenly  become  elastic. 

The  contractions  in  the  small  intestine  are  usually  smaller  than 
in  the  large  intestine. 

Meteorism  in  the  milder  cases  is  not  marked,  as  the  gas  can  pass 
the  obstruction.  Later  it  may  become  quite  marked,  and,  as  in 
acute  obstruction,  may  be  local  or  general  in  character. 

If  the  obstruction  is  in  the  lower  colon  or  rectum,  it  will  be  most 
pronounced  at  first  in  the  course  of  the  colon,  on  the  sides  of  the 
abdomen,  and  in  the  epigastrium. 

If  in  the  lower  ileum,  the  distention  is  more  pronounced  in  the 
umbilical  and  hypogastric  regions,  and  the  lumbar  regions  are  re- 
laxed (undistended) . 

Later  there  may  be  more  general  distention  and  the  barrel- 
shaped  abdomen.  Local  manifestations  of  meteorism  are  described 
under  Acute  Obstruction. 

One  of  the  important  types  is  chronic  intussusception,  which 
may  develop  after  an  acute  attack  has  subsided  or  may  occur  as 
such  from  its  incipiency.  It  takes  place  most  frequently  in  the 
ileocecal  form.  Some  of  the  latter  cases  may  continue  for  months 
or  even  years.  The  pain  is  paroxysmal,  but  may  entirely  intermit. 
There  may  be  attacks  of  pain  daily,  or  every  few  days  or  weeks. 
As  the  disease  advances  the  intervals  grow  shorter.  Vomiting  is 
not  marked.  Often  diarrrhea  is  present  or  constipation  alternating 
with  diarrhea.     Blood  may  be   passed   and  tenesmus  is    at  times 


INTESTINAL    OBSTRUCTION — ACUTE    AND    CHRONIC  66l 

present.  Palpation  shows  the  presence  of  a  tumor  in  about  50  per 
cent,  of  the  cases,  or  a  tumor  can  be  felt  in  the  rectum.  Local 
meteorism  may  be  present.  Occasionall}^  the  invaginated  part  may 
slough  off  and  perfect  recovery  ensue  or,  again,  ultimate  stenosis 
may  follow.     Death  may  occur  through  perforation. 

Chronic  Obstruction  through  Fecal  Accimiulation. — This  is 
more  common  in  females  and  usually  in  our  older  patients.  The 
history  is  of  habitual  constipation.  At  times  large  amounts  of  fecal 
matter  are  voided  by  enema.  Scybalffi  are  frequently  present. 
There  are  digestive  disturbances,  flatulence,  loss  of  appetite,  eruc- 
tation, fetid  breath,  headache,  dizziness,  and  symptoms  of  auto- 
intoxication; there  may  be  oppression  in  breathing  from  distention, 
an  unhealthy  appearance  of  the  skin,  and  a  foul  tongue.  There 
may  be  pains  in  the  thighs,  legs,  and  genitals  due  to  pressure  on  the 
lumbar  or  sacral  nerves.     The  patient  may  be  very  neurasthenic. 

Distention  and  gurgling  may  occur.  There  are  colicky  pains,  but 
usually  they  are  not  severe. 

If  untreated,  the  condition  may  become  worse,  the  constipation 
increase,  and  all  the  symptoms  of  chronic  or  even  of  acute  obstruc- 
tion develop,  as  already  described  under  Fecal  Obstruction.  The 
vomiting  may  even  become  feculent. 

Palpation  shows  the  presence  of  a  tumor  frequently  in  the  colon, 
especially  in  the  cecum,  sigmoid,  or  other  flexures.  It  may  be  hard 
and  uneven,  and  will  often  "pit"  on  pressure.  It  is  not  painful  on 
pressure,  as  a  rule.  Rectal  examination  generally  shows  the  pres- 
ence of  scybalae.  I  have  treated  a  case  in  which  apparently  nearly 
the  entire  abdomen  was  occupied  by  the  fecal  tumor.  Operation  for 
"tumor"  had  been  advised.  As  a  result  of  80  bowel  movements 
in  one  week  the  tumor  disappeared.  The  patient  had  had  no  bowel 
action  for  three  weeks.  Enemata,  and  especially  recurrent  rectal 
irrigation,  and  later,  catharsis  will  reduce  the  size  of  the  tumor.  I 
have  seen  cases  in  which  acute  flexions  or  angulations  of  the  sigmoid 
and  colon  have  been  factors  in  the  production  of  this  condition. 
They  are  well  described  by  J.  P.  Tuttle.^ 

Rectal  Stricture. — There  are  the  symptoms  of  progressive  con- 
stipation at  times  with  alternating  diarrhea,  with  mucus  and  pus 
in  the  stools,  colicky  pains,  tympanites,  tenesmus,  and  loss  of  appe- 
tite. There  may  be  hemorrhoids  and  rectal  prolapse.  Digital  ex- 
amination, exploration  with  a  rectal  bougie  or  the  proctoscope,  will 
demonstrate  the  constriction. 

With  stricture  the  pressure  on  the  examining  finger  remains  con- 
stant and  is  not  like  sphincteric  spasm,  which  soon  relaxes.  Many 
of  the  strictures  are  within  the  finger  reach,  within  4  to  6  centimeters 
up  the  bowel;  if  not  within  reach  but  suspected,  a  Wales  rectal  bougie 

1  New  York  Medical  Journal,  etc.,  March  14,  1908.  Gant  has  also  demon- 
strated that  prolapse  of  the  sigmoid  flexure  is  a  cause,  and  relief  has  been  secured 
by  suspension  of  the  sigmoid. 


662  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

or  soft  tube  can  be  employed  for  the  examination.  The  degree  of 
stricturing  can  be  determined  by  using  tubes  or  bougies  of  varying 
sizes.  It  is  preferable  to  pass  the  speculum  up  to  the  point  of  stric- 
ture, so  as  to  examine  its  nature  thoroughly.  It  is  often  advisable 
to  remove  a  small  section  under  cocain  for  microscopic  examination. 
With  malignant  stricture  there  are  cachexia,  loss  of  weight,  metas- 
tases, and  the  symptoms  described  under  Carcinoma. 

Complications. — Above  the  stenosis  on  account  of  the  ulceration 
we  may  have  circumscribed  peritonitis  and  abscess  or  perforation 
with  general  peritonitis.  The  abscess  may  rupture  into  other 
viscera  or  perforate  the  abdominal  wall.  The  chronic  condition 
may.  suddenly  become  acute,  and  severe  collapse  occur  with  death, 
or  thrombosis  of  some  of  the  veins,  or  pyemic  processes,  or  the  patient 
may  die  of  inanition. 

Diagnosis. — The  gradually  increasing  constipation;  colic  at- 
tacks with  frequent  stoppage  of  the  bowels,  alternating  at  times  with 
diarrhea  and  the  temporary  relief  of  symptoms;  visible  peristaltic 
movements  with  tetanic  rigidity  of  the  intestines;  at  first  local 
meteorism  and,  later,  the  tendency  to  the  barrel-shaped  abdomen; 
the  presence  of  gastro-intestinal  disturbances  of  varying  degree  and, 
frequently,  loss  of  weight  are  suggestive  of  the  obstruction.  Rectal 
examination  is  always  of  importance. 

If  the  constipation  is  of  long  standing,  in  an  elderly  person  or 
invalid,  and  there  is  no  cachexia,  the  tumor  movable  and  doughy 
on  pressure,  scybalae  being  passed,  and  at  times  accumulation  felt 
in  the  rectum,  fecal  tumor  is  evident.  These  occur  chiefly  in  the 
caput  coli,  sigmoid,  colon  flexures,  or  rectum. 

With  carcinoma  there  is  marked  cachexia^  and  the  tumor  is  hard 
and  solid,  occurs  mostly  in  the  caput  coli,  sigmoid,  and  rectum, 
and  more  frequently  in  persons  over  forty-five.  There  is  slight  or 
moderate  leukocytosis,  and  also  anemia. 

Tuberculous  tumor  of  the  cecum  and  peridiverticulitis  (chronic) 
of  the  sigmoid  must  be  held  in  consideration  as  causes. 

With  chronic  intussusception  the  mass  is  usually  of  sausage 
shape,  and  shows  the  peculiarity  that  it  sometimes  feels  hard  and 
sometimes  soft  on  palpation;  there  are  mucus  and  blood  in  the  stool. 

External  tumors  can  generally  be  appreciated.  Vaginal  examina- 
tion should  be  made.  If  there  have  been  attacks  of  peritonitis,  bands 
and  adhesions  would  be  suspected. 

A  previous  history  of  diarrhea,  dysentery,  syphilis,  or  tubercular 
difficulty  would  suggest  ulcerative  stenosis. 

Stricture  of  the  small  intestine  is  most  frequently  due  to  adhe- 
sions or  tubercular  ulcer.  In  the  large  intestine  stercoral,  syphilitic, 
or  dysenteric  ulcers  are  to  be  considered,  chiefly  carcinoma  or  pelvic 

1  In  the  scirrhous  type  of  carcinomatous  stricture,  cachexia  may  be  scarcely 
noticeable  for  a  considerable  period.  The  progressive  constipation  and  age  of  the 
patient  are  significant. 


INTESTINAL   OBSTRUCTION — ACUTE    AND    CHRONIC  663 

inflammation,  perityphlitic  adhesions,  and,  more  rarely,  tuberculosis 
of  the  cecum  and  chronic  peridiverticulitis. 

Course  and  Prognosis. — This  depends  on  the  etiology  and 
severity  of  the  obstruction.  With  non-malignant  stricture  of  the 
bowel  of  moderate  type,  or  in  the  fecal  obstruction  cases,  not  pro- 
gressive, the  patient  by  proper  regulation  of  diet  may  live  many 
years.  With  malignancy  the  prognosis  is  fatal  unless  relieved  by 
early  operation;  chronic  intussusception  occasionally  clears  up,  but 
the  prognosis,  as  a  rule,  is  bad.  In  progressive  cases  the  symptoms 
rapidly  become  worse  and  life  is  shortened,  with  death  from  final 
acute  obstruction.  Unless  radical  operation  is  performed,  complica- 
tions such  as  peritonitis,  pyemic  processes,  etc.,  hasten  the  final 
result. 

Treatment. — If  chronic  obstruction  suddenly  or  gradually  devel- 
ops into  acute  obstruction,  the  same  indications  for  treatment 
exist  as  in  the  latter  condition. 

In  the  chronic  cases  the  proper  regulation  of  diet,  omitting  those 
things  which  will  mechanically  fill  up  the  intestines  and  a  careful 
regulation  of  the  bowels,  are  most  important.  Substances  that  give 
a  large  residue  of  fecal  matter,  which  are  irritating  and  extremely 
constipating,  should  be  excluded. 

Matzoon,  kumyss,  buttermilk,  bacillac,  lactone-buttermilk,  and 
kefir  milk  are  excellent.  Milk  agrees  well,  as  a  rule,  with  most 
cases  and  is  readily  digested,  while  others  it  constipates  and  is 
undigested. 

Raw  eggs  can  be  beaten  up  in  milk,  and  soft-boiled  eggs,  broths, 
soups,  and  gruels  administered.  Sanatogen  (flavored)  and  somatose 
are  of  value,  administered  in  the  broths  or  milk. 

If  the  stenotic  symptoms  are  progressive  6r  fairly  marked, 
liquid  or  soft  diet  alone  should  be  given. 

In  milder  cases  scraped  beef,  tender  meat  (well  divided),  butter, 
a  small  amount  of  well-toasted  bread,  and  moderate  in  quantity, 
rice,  sago,  and  mashed  potatoes  in  small  amount  are  admissible. 
The  patient  should  eat  a  small  quantity  frequently  and  should  take 
sufficient  food  to  preserve  his  nutrition.  \'ery  hot  and  cold  drinks 
should  be  avoided.  Irritating  food,  such  as  mustard,  spices,  pepper, 
vinegar,  fruits  in  bulk,  and  green  vegetables  in  large  amounts,  should 
be  forbidden.  Substances  giving  a  large  residue  of  fecal  matter 
should  also  be  cut  off.  Spinach  I  have  found  of  service  to  aid 
bowel  action.     Fats,  such  as  cream  and  butter,  are  useful. 

Fresh  fruit  juices  are  valuable,  and  the  administration  of  a  glass 
of  water  on  rising  is  of  service. 

Bowels. — The  bowels  must  be  moved  every  day.  Injections  of 
soapsuds  enemata  of  medium  size,  not  over  i  quart  (liter),  with 
the  hips  elevated ;  Kussmaul's  method  of  oil  injection,  Oj  (500  cc.) 
or  more,  being  retained  over  night ;  or  the  addition  of  olive  oil  to 
the  enema,  mild   cathartics,  such  as  cascara,  rhubarb,  syrup  of  figs. 


664  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

phenolphthalein,  and  occasionally  sulphate  of  magnesia  or  Apenta 
water,  are  of  service.  Under  Chronic  Constipation  numerous  rem- 
edies are  described. 

Enteroclysis  (recurrent)  is  valuable  in  all  cases. 

]Massage,  vibratory  massage,  and  electricity  are  of  ser\dce  only  in 
cases  due  to  fecal  accumulation. 

If  diarrhea  is  present,  unless  the  patient  is  weakened  thereby, 
it  should  not  be  checked.  In  the  latter  event  mild  preparations, 
such  as  bismuth  subnitrate,  chalk  mixture,  or  chalk  and  catechu,  are 
preferable  to  opiates.  If  there  are  small  diarrheal  movements,  evi- 
dently a  diarrhea  associated  with  constipation,  then  a  dose  of  castor 
oil  or  a  saline  cathartic  is  indicated. 

For  Colic  Attack  and  Peristaltic  Movements. — Hot  applications  to 
the  abdomen  are  indicated  and  a  recurrent  irrigation  of  normal 
saline  solution  at  115°  to  120°  F.  is  of  value,  to  be  given  for  ten  to 
twenty  minutes.  The  latter  removes  gas  and  clears  the  bowels. 
Enema ta  also  can  be  administered. 

Tincture  of  belladonna,  TTLx  (0.59),  once  or  twice,  is  of  use  to 
allay  spasm,  or  by  suppository,  extract  of  belladonna,  gr.  ^  to  |- 
(0.016-0.024).  Opium  I  avoid  if  possible,  and  then  only  i  to  |  gr. 
(0.008-0.016)  of  morphin  or  codein  by  hypodermic.  It  should  be 
g  ven  only  to  allay  severe  pain. 

For  vomiting  and  distention  lavage  is  indicated. 

Cerium  oxalate  with  bismuth  and  soda  will  check  vomiting,  also 
TTLj  (0.059)  doses  of  Fowler's  solution  of  arsenic  every  hour  for  four 
doses. 

Cocain,  which  has  been  suggested,  is  a  dangerous  and  pernicious 
drug.  I  have  seen  complete  collapse  after  its  use  in  as  small  doses 
asyu  gr-  (0.006). 

Lavage  is  of  special  value  in  temporarily  allaying  symptoms  if 
the  stenosis  is  in  the  small  intestine. 

If  chronic  fecal  impaction,  our  first  efforts  should  always  be 
directed  from  below. 

Hardened  scybalse  should  be  removed  from  the  rectum  by  the 
finger,  oil  injections,  and,  later,  by  soapsuds  enemata  and  recurrent 
rectal  irrigations.     Olive  oil  can  be  given  by  mouth. 

Later,  cathartics,  massage,  electricity,  and  vibratory  massage  are 
of  servdce. 

Electric  enteroclysis  I  have  found  useful  in  obstinate  cases  of  fecal 
impaction. 

Tincture  of  belladonna,  TTLx  fo.59)  three  or  four  times  a  day,  and 
strychnin,  gr.  ^-^  (0.002)  t.  i.  d.,  are  of  value.  Eserin  sulph.,  gr. 
TTo  to-^  (0.00065-0.00108),  may  be  required. 

Mild  cases  of  rectal  stricture,  providing  they  are  not  malignant, 
can  be  benefited  by  dilatation  for  ten  to  fifteen  minutes  evers* 
two  to  three  days  with  different  sized  bougies.  Operation  on  the 
stricture  may  be  necessay  in  some  cases.    Thiosinamin  can  first  be 


INTESTINAL    OBSTRUCTION — ACUTE    AND    CHRONIC  665 

tried,  injected  into  the  bowel  or  by  hypodermic.  Dose,  gr.  h  to  ih 
(0.033-0.1);  or  by  hypodermic,  gr.  i  (0.065),  in  15  per  cent,  alcohol 
solution  or  lo  per  cent,  glycerinated  solution. 

Operation. — ^Nlost  types  of  chronic  intestinal  obstruction  grow 
worse,  except  those  due  to  fecal  impaction.  In  mild  types  of  rectal 
stricture  local  dilatation  may  be  palliative  and  keep  the  patient  com- 
fortable. 

Malignant  growths  must  be  extirpated  as  soon  as  possible.  Stric- 
tures must  be  treated  according  to  their  location — in  the  rectum,  by 
division  and  dilatation  or  by  resection.  In  other  regions,  entero- 
plastv,  splitting  the  gut  parallel  to  its  axis,  at  the  same  time  dividing 
the  stricture  and  uniting  the  incision  transversely,  has  been  success- 
ful. Complete  excision  may  be  necessary,  with  or  without  employ- 
ing Murphy's  button  to  unite  the  ends.  Anastomosis  of  the  bowel 
above  to  that  portion  lying  below  the  stricture  may  be  required.  In 
stricture  of  the  colon  in  cases  quite  prostrated  a  simple  colotomy 
above  the  point  of  stenosis  is  indicated. 

Adhesions  should  be  severed  and  tumors  compressing  the  bowel 
removed.  If  the  chronic  obstruction  be  due  to  any  of  the  causes 
which  may  also  produce  acute  obstruction,  appropriate  surgical 
measures  are  indicated. 

Early  operation  is  preferable  in  most  cases  of  chronic  obstruction. 

In  acute  obstruction  engrafted  on  chronic  stenosis,  there  should 
be  immediate  resort  to  surgery. 


CHAPTER    XXXII 

NERVOUS  DISEASES  OF  THE  INTESTINES 

Under  this  heading  are  included  those  conditions  due  to  pen^er- 
sion  of  the  innervation  of  the  intestines  independent  of  anatomic 
lesions  of  the  intestinal  wall  or  of  distant  organs. 

In  manv  cases  the  neurotic  manifestations  in  the  intestines  are 
an  independent  manifestation  of  some  general  neurosis,  such  as  of 
neurasthenia,  hysteria,  or  hypochondriasis.  Some  few  cases  result 
purely  from  functional  perversion  of  the  intestinal  ners^es. 

Intestinal  neuroses  may  be  divided  into  motor,  sensory,  and 
secretory.  They  often  exist  in  combination.  Psychic  influences,  such 
as  fear,  fright,  worry,  and  anxiety,  may  be  causes,  as  may  reflexes 
from  some  diseased  organs,  such  as  the  stomach  or  genito-urinary 
tract. 

The  nerve-centers  influencing  peristalsis,  iMeissner's  and  Auer- 
bach's  plexuses,  have  been  described  in  the  chapter  on  Physiology  of 
Digestion,  Part  I,  under  Nervous  Control  of  Peristalsis,  page  41. 

Secretion  seems  to  be  dependent  to  a  great  extent  upon  the  gan- 
glionic plexus.  Moreau^  ligated  an  intestinal  coil  and  severed  all  the 
ner\^es  passing  to  it.  In  a  few  hours  it  was  filled  with  fluid,  showing 
amylolytic  qualities  and  containing  albumin. 

After  ingestion  of  food  into  the  stomach,  secretion  takes  place  in 
the  lower  part  of  the  intestines  before  the  arrival  of  the  chyme.  This 
was  demonstrated  by  Quincke  and  Demant. 

Vasomotor  filaments  exist  in  the  intestines  as  stimulation  of  the 
splanchnic  causes  contraction,  and  its  section  causes  dilatation  of  the 
intestinal  blood-vessels.     They  are  also  concerned  with  absorption. 

Sensory  filaments  exist  in  the  intestines,  since  stimuli  of  greater 
intensity  than  normal,  such  as  the  ingestion  of  beans  or  cabbage,  may 
give  rise  to  sensations  of  pain  or  pressure.  Kast  and  ]\Ieltzer-  have 
demonstrated  experimentally  that  the  sensation  of  pain  exists  in  the 
intestines,  and  that  laparotomy,  under  cocain,  causes  anesthesia  of 
the  intestines  through  the  cocain  being  carried  b}^  the  blood. 

MOTOR  NEUROSES   OF  THE  INTESTINES 

Peristaltic  Unrest  (Tormina  Intestinorum) . — This  condition  con- 
sists in  marked  rotary  or  rolling  movements  of  the  intestines,  so  that 
they  frequently  become  visible.  It  is  usually  seen  in  patients  with 
hysteria  or  hypochondriasis.  Occasionally  it  is  an  independent  affec- 
tion.    It  is  almost  exclusively  seen  in  the  small  intestine. 

1  Centralbl.  fiir  die  Med.  Wissensch,  186,  No.  14. 

2  Medical  Record,  Dec.  29,  1906. 

666 


NERVOUS    DISEASES    OF   THE    INTESTINES  667 

Peristaltic  restlessness,  which  accompanies  complete  or  incom- 
plete occlusion  of  the  intestines,  is  not  included  herein.  There  is  not 
the  peculiar  stiffening  of  the  intestinal  coils,  as  is  present  with  steno- 
sis, and  other  symptoms  of  that  condition  are  absent.  Occasionally 
the  condition  occurs  in  persons  presenting  no  other  nervous  symp- 
toms, as  after  the  ingestion  of  highly  spiced  or  indigestible  foods, 
after  the  excessive  use  of  tobacco,  mental  excitement,  or  too  much 
brain  work. 

Clinically,  there  are  rolling,  gurgling,  squelching  noises  in  the 
abdomen  of  varying  intensity.  They  can  often  be  heard  at  some 
distance  and  are  a  source  of  mortification  to  the  patient.  Pain,  as  a 
rule,  is  not  present.  The  movements  of  the  intestines  may  occasionally 
become  visible  and  palpable.  Eructations  sometimes  occur  when 
peristaltic  unrest  of  the  stomach  is  associated. 

Attacks  occur  at  irregular  intervals  and  may  take  place  during 
menstruation. 

Diagnosis. — Stenosis  of  the  bowel  must  be  excluded.  The  ner- 
vous type  of  peristaltic  restlessness  of  the  intestines  is  readily  recog- 
nized.   Prognosis  is  favorable. 

Treatment. — ^This  should  be  directed  toward  the  tone  of  the 
nervous  system.  Heat  externally  applied  and  the  drinking  of  hot 
water  during  the  attack  are  of  value.  Spicy  and  indigestible  food 
should  be  excluded.  Priessnitz  compresses  should  be  applied  to  the 
abdomen  at  night.  The  bromids,  valerian,  and  asafetida  are  useful. 
Arsenic  alone  or  combined  with  iron  should  be  employed  in  anemia. 
If  there  is  any  disturbance  of  the  bowels  (diarrhea  or  constipation) 
it  should  be  properly  regulated.  Rarely  a  small  dose  of  opiate, 
alone  or  combined  with  belladonna,  is  required.  If  the  attacks  occur 
at  night,  chloral  hydrate,  gr.  15  (i.o),  or  veronal,  gr.  'j^  (0.5),  sul- 
phonal  or  trional,  gr.  10  (0.6),  may  be  necessary.  Electricity  and 
massage  have  been  recommended.     Change  of  climate  is  beneficial. 

Nervous  Diarrhea. — The  exaggerated  peristaltic  movements 
occur  not  only  in  the  small  but  also  in  the  large  intestine.  They  may 
be  limited  to  the  colon  in  some  cases.  There  is  an  increased  transu- 
dation of  fluid  due  to  nervous  influences.  The  reader  should  refer  to 
a  description  of  this  condition  under  Diarrhea  (page  474).  Spastic 
constipation,  due  to  local  enterospasm  and  also  spasm  of  the 
sphincter,  sometimes  occurs  in  neuropathic,  hypochondriac,  or 
hysteric  subjects.  These  conditions  are  described  under  Constipa- 
tion (page  461). 

Paralysis  of  the  Intestines.— Paralysis  resulting  from  a  me- 
chanical obstacle  to  the  passage  of  the  intestinal  contents  has  been 
described.  Primary  paralysis  of  the  intestines  without  any  organic 
obstacle  will  itself  cause  symptoms  of  obstruction.  The  reader  is 
further  referred  to  dynamic  ileus  (page  651). 

There  are  several  forms  of  this  condition :  i .  An  intestinal  coil 
may  become  paralyzed  after  forced  reposition  of  a  hernia  or  after 


668  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

incarceration;  it  may  be  due  to  direct  traumatism,  to  abdominal 
operation,  or  to  inflammation  or  ulcerative  processes  of  the  intes- 
tines. 

2.  It  may  result  from  reflex  irritation  of  the  inhibitory  nerves  of 
the  muscular  coats  of  the  intestines,  especially  where  there  is  injury 
or  inflammation  which  does  not  necessarily  involve  the  bowel. 

Toxemia  may  be  a  factor.  Contusion  of  the  testicles,  abdominal 
abscess,  anesthesia,  uremia,  etc.,  are  causes. 

3.  Neuroses,  melancholia,  hypochondria,  or  affections  of  the  ner- 
vous system,  such  as  meningitis,  brain  tumors,  tabes,  myelitis,  etc., 
are  also  causes.  Atony  of  the  intestines,  leading  to  coprostasis,  has 
been  suggested  as  a  cause  of  intestinal  paralysis.  It  would  seem  that 
the  symptoms  are  produced  by  occlusion.  Intestinal  atony  is  really  a 
subparetic  condition,  and  the  nervous  type  is  described  under  Chronic 
Constipation  (page  460). 

Meteorism  in  hysteria  is  probably  due  to  sudden  paresis  of  the 
muscular  coat  of  the  bowel.    (See  Meteorism,  pages  451  and  452.) 

Treatment. — Removal  of  fecal  impaction  by  the  fingers  if  pres- 
ent, enemata  of  soapsuds  containing  olive  oil,  oviij  (250  cc),  and 
glycerin,  5ij  (8.0),  electric  enteroclysis,  enteroclysis,  enemata,  mas- 
sage, and  electricity  are  useful.  With  fecal  impaction,  mercury,  o  10 
to  20  (300.0-600.0),  given  through  a  stomach -ttibe,  is  of  value.  It 
might  otherwise  enter  the  larynx.  Various  cathartics,  such  as 
castor  oil,  oj  to  ij  (32.0-64.0),  olive  oil,  oiv  (128.0);  physostigmin 
sulphate,  gr.  yU  to  go  (0.0006-.001),  may  be  employed.  Lavage, 
followed  by  the  administration  of  the  cathartic  through  the  stomach- 
tube,  is  useful. 

For  further  treatment,  the  methods  pursued  in  dynamic  ileus 
should  be  consulted  (page  654). 

Paralysis  of  the  Sphincters. — It  occurs  as  one  of  the  symptoms 
of  rectal  affections.  Tenesmus  may  lead  to  exhaustion.  Ulceration 
and  infiltration  of  the  rectum  at  times  involve  the  sphincters,  inter- 
fering with  their  function  or  destroying  it. 

Improper  methods  of  operations  on  the  rectum  may  cause  paral- 
ysis. Accumulation  of  feces  may  impair  the  tone  of  the  muscles. 
Diseases  of  the  brain  and  spinal  cord  may  cause  paralysis  of  the 
sphincters.     //  may  be  a  pure  neurosis. 

Some  patients  are  not  able  to  keep  the  rectum  tightly  closed  and  a 
small  amount  of  discharge  continually  escapes.  In  others  involuntary 
movements  occur  after  excitement,  exertion,  or  during  urination,  there 
being  only  a  partial  paresis.  With  complete  paralysis,  flatus  and 
feces  escape  involuntarily,  even  when  resting. 

With  paralysis  resulting  from  proctitis,  hemorrhoids,  stricture, 
etc.,  there  is  a  continuous  dripping  of  mucous  secretion  which  irri- 
tates the  skin. 

Diagnosis. — The  anus  appears  patulous  and  several  fingers  can  be 
introduced  into  the  rectum  without  resistance.    To  diagnose  purely 


NERVOUS    DISEASES   OF    THE    INTESTINES  669 

nervous  paralysis,  anatomic  lesions  must  he  excluded  by  means  of 
examination  with  0  specidum. 

Prognosis. — This  depends  upon  the  cause — in  the  pure  neuroses  it 
is  favorable. 

Treatment. — Thorough  evacuation  of  the  bowels,  preferably  by 
enemata  twice  daily,  is  important.  The  addition  of  alum,  oj  (4.0) 
to  Oj  (500  cc.)  of  water  by  enema,  is  useful.  If  due  to  nervous  con- 
ditions, electricity  and  massage,  especially  local  vibrations,  as  sug- 
gested by  J.  P.  Tuttle,  are  beneficial.  Tonics,  such  as  iron  and 
arsenic,  are  useful.  Strychnin,  gr.  gV  to  -g-V  (0.001-0.0015),  by  hy- 
podermic into  the  anal  folds  has  been  recommended  by  Rosenheim. 
General  improvement  of  the  nervous  system  and  at  times  change  of 
scene  are  indicated. 

Occasionally  difficulty  in  urination  and  straining  may  cause 
paresis  of  the  sphincter.    Catheterization  will  improve  this  condition. 

In  the  cases  in  which  the  nervous  condition  is  not  responsible, 
but  some  anatomic  lesion,  appropriate  treatment  is  indicated. 

SENSORY  NEUROSIS  OF  THE  INTESTINES 

I  agree  with  Riegel  that  true  colic  is  not  a  sensory  neurosis.  On 
page  453  I  have  called  attention  to  the  fact  that  the  pain  of  colic  is 
produced  by  tetanic  contractions  of  the  intestinal  muscles,  and  that 
it  is  a  secondary  symptom. 

Hyperesthesia  of  the  Intestines. — Under  normal  conditions 
digestion  is  carried  on  without  producing  any  sensation  whatever. 
In  cases  of  neurasthenia,  hysteria,  and  hypochondriasis  the  patient 
may  be  conscious  of  abnormal  sensations  in  the  intestines  after  the 
ingestion  of  food.  They  may  occasionally  appear,  after  violent 
emotion  or  shock.  These  sensations  consist  in  a  feeling  of  fulness, 
stabbing,  burning,  tearing,  and  as  if  the  ingesta  were  moving  about 
in  the  abdomen.  Occasionally  delusions  may  develop.  In  some  there 
is  local  hyperesthesia,  especially  in  the  rectum.  There  is  a  feeling  of 
tenesmus  or  fulness,  as  if  some  foreign  material  were  impacted  there- 
in, though  the  rectum  is  normal  and  contains  no  fecal  matter.  In 
others  pressure  and  weakness  occur  in  this  region,  or  there  is  burning, 
tickhng,  itching,  stabbing,  or  a  cutting  feeling,  at  times  combined 
with  voluptuous  sensations. 

Anesthesia  of  the  Rectum. — In  these  patients  the  desire  for 
defecation  is  absent.  In  pronounced  cases  movement  may  occur 
without  being  felt.  Such  conditions  are  met  with  only  in  patients 
with  spinal  and  brain  trouble,  or  in  the  old  and  decrepit.  Paralysis 
of  the  sphincters  may  occasionally  accompany  this  condition. 

Treatment. — This  must  be  directed  toward  the  improvement  of 
the  nervous  condition.  Change  of  climate  and  hydrotherapy  are 
valuable.  Highly  spiced  food,  alcohol,  and  red  meats  should  be  for- 
bidden. 


670  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

Abnormal  sensations  in  the  rectum  may  be  improved  by  cold  rec- 
tal douches,  sitz-baths,  the  cold  prostatic  cooler,  such  as  I  advocated 
in  the  treatment  of  hemorrhoids,  and  by  rectal  galvanization. 

With  rectal  anesthesia  cleansing  enemata  are  useful.  It  mav  be 
necessary  to  wear  a  rectal  obturator  (Fig.  232)  to  prevent  soiling. 

Nervous  Enteralgia  (Neuralgia  Mesenterica). — Aside  from  en- 
teralgia  due  to  irritating  factors,  it  may  result  from  a  perverted  state 
of  the  sensory  intestinal  nerves.  This  condition  is  not  due  to  spasm 
of  the  intestinal  muscles,  like  colic,  but  to  a  neuralgic  affection  of 
the  bowels.  It  appears  as  a  primary  affection  and  is  found  in 
patients  troubled  with  hysteria,  neurasthenia,  or  spinal  difficulty.  It 
may  occasionally  be  reflex,  from  abnormal  conditions  of  the  kidneys, 
bladder,  uterus,  ovaries,  and  liver.  It  may  occur  as  a  neuralgic  con- 
dition even  after  the  removal  of  some  primary  cause  in  the  intestines. 
The  first  symptom  is  pain,  which  usually  begins  in  the  umbilical 
region,  mild  at  first,  but  gradually  increasing  in  intensity.     It  may 


Fig.  232.— Rectal  obturator. 

radiate  in  various  directions.  Pressure  over  the  abdomen  and  the 
passage  of  flatus  usually  relieve  the  pain.^  The  bowels  may  be  nearly 
normal  or  constipated.  Appetite  and  digestion  may  be  good.  Pal- 
pitation, dyspnea,  strangury,  etc.,  may  occur. 

Neuralgic  attacks  can  occur  in  lead-poisoning  without  the  true 
spasm.  Hemmeter  has  reported  3  cases  of  gouty  neuralgia  of  the 
intestines.  Romberg  holds  that  the  abnormal  crisis  of  tabes  dorsahs 
is  due  to  nervous  enteralgia.  Examination  of  the  symptoms  demon- 
strates that  true  colic  is  present.  The  Romiberg  symptom,  Argvll- 
Robertson  pupil,  and  absence  of  patellar  reflexes  are  diagnostic. 

Hypogastric  Neuralgia  (Romberg). — In  some  cases  of  tabes  there 
is  a  purely  local  form  of  neuralgia,  Hmited  to  the  rectum.  The 
attacks  are  characterized  by  violent  tenesmus,  paroxvsms  of  pain,  a 
feeling  as  if  a  red-hot  iron  were  inserted  in  the  rectum,  and  occasion- 
ally diarrhea.  This  condition  is  also  frequently  found  in  diabetes  and 
in  women  having  uterine  trouble,  piles,  or  who  are  neurasthenic. 

^  The  pain  may  be  of  a  cutting  or  stabbing  type,  and  may  even  produce  shock 
or  syncope. 


NERVOUS    DISEASES    OF    THE    INTESTINES  67 1 

The  picture  presented  by  nervous  enteralgia,  on  the  other  hand, 
as  Riegel  remarks,  may  occupy  an  intermediate  position  between 
peritonitis  and  cohc  (pseudoperitonitis).  Violent  attacks  of  pain 
occur  in  the  abdomen  at  short  intervals.  Associated  with  this  is 
frequently  pronounced  collapse,  with  great  abdominal  tenderness 
on  light  pressure.  Vomiting,  which  is  usually  present  in  peritonitis, 
is  always  absent  in  these  cases.  The  skin  of  the  abdomen  is  generally 
hyperalgesic.  The  functions  of  the  intestines  and  stomach  between 
attacks  are  undisturbed,  and  the  patients  feel  perfectly  well. 

Treatment. — This  should  be  directed  toward  improvement  of  the 
hysteria  and  neurasthenia.  Change  of  climate,  hydrotherapy,  mas- 
sage, electricity,  and  moral  treatment  are  of  service.  Arsenic  is  val- 
uable.   The  bowels  should  be  kept  regular  and  a  simple  diet  advised. 

With  neuralgia  hypogastrica,  if  there  is  local  disturbance,  this 
should  be  treated.  Warm  sitz-baths  and  hot  enemata  are  useful. 
Occasionally  an  opium-and-belladonna  suppository  may  be  required. 
Tabes  should  receive  treatment. 

SECRETORY   NEUROSES   OF   THE   INTESTINES 

Though  secretion  in  the  intestines  immediately  follows  the 
entrance  of  food  into  the  stomach,  thus  demonstrating  the  pres- 
ence of  secretory  nerves  in  the  intestines,  we  still  have  little  knowl- 
edge of  the  subject. 

Nervous  diarrhea,  which  has  been  described  on  page  474  as  a 
motor  neurosis,  is  often  accompanied  by  an  increased  flow  of  intes- 
tinal juice.  Increased  intestinal  secretion  is  found  in  membranous 
enteritis,  though  I  do  not  consider  this  disease  a  pure  neurosis  of 
secretion. 

INTESTINAL   NEURASTHENIA 

Combinations  of  the  intestinal  neuroses  frequently  occur.  Rosen- 
heim designates  such  cases  as  intestinal  neurasthenia.  The  appetite 
is  good  and  the  symptoms  usually  appear  when  intestinal  digestion 
takes  place — about  two  to  three  hours  after  meals. 

There  are  pressure,  tension,  and  griping  in  the  abdomen.  Occa- 
sionally there  is  nausea,  and  at  times  an  evacuation  of  the  bowels 
occurs  accompanied  with  painful  sensations  in  the  abdomen  and 
anus.  Palpitation  occurs  at  times;  sometimes  flashes  of  heat  or  cold. 
Generally  the  patient  feels  worse  when  resting  in  the  recumbent 
position  than  when  walking  about.  The  symptoms  usually  disap- 
pear in  a  couple  of  hours  to  return  later  after  a  meal.  Constipa- 
tion usually  is  present. 

The  cjuality  of  the  food  docs  not  excri  nuy  influence  on  the  symp- 
toms.    Borborvgmi  and  diarrhea  occasionally  are  present,  and  the 
latter  in  the  middle  of  the  night  or  in  the  early  morning.       Indigesti- 
ble foods  are  often  well  borne,  while  at  other  times  small  meals  con- 
sisting of  light  food  cause  severe  symptoms.    Gastric  neurasthenia  is 


672  DISEASES  OF  THE   STOMACH   AND   INTESTINES 

sometimes  associated.  This  condition  is  found  among  the  hysteric 
and  neurasthenic. 

Diagnosis. — Anatomic  lesions  causing  these  symptoms,  intestinal 
dyspepsia,  and  enteroptosis  must  be  excluded. 

Treatment. — The  general  nervous  condition  must  be  toned  up; 
iron,  arsenic,  strychnin,  and  the  bromids  are  indicated,  and  ample 
feeding  is  required.  Indigestible  substances  should  be  avoided,  also 
red  meats,  to  lessen  the  nervous  irritability.  The  sour  milks,  such 
as  bacillac,  etc.,  are  of  value. 

MUCOUS  COLIC   (MEMBRANOUS  ENTERITIS) 

Among  the  best -known  synonyms  for  mucous  colic  are  mucous 
colitis,  membranous  colitis,  membranous  or  pseudomembranous  en- 
teritis, and  tubular  diarrhea.  In  all,  there  are  about  twenty-five 
names  for  this  condition. 

History, — Although  no  distinct  accounts  of  this  disease  occur  in 
the  writings  of  the  ancients,  yet  there  may  be  detected  some  of  its 
peculiar  features  in  the  description  of  certain  pathologic  conditions 
grouped  under  diarrhea,  dysentery,  etc.  J.  Mason  Good,  in  1825,  was 
the  first  to  classify  the  disease,  calling  it  tubular  diarrhea.  Wood- 
ward descibed  it  in  the  ' '  Medical  and  Surgical  History  of  the  War  of 
the  Rebellion."  Siredy  contributed  a  valuable  paper  in  1869.  Da- 
Costa,  in  1 87 1,  described  the  nervous  elements  of  the  disease,  stating 
that  the  condition  is  not  a  true  inflammation.  Leyden's  work,  in 
1882,  gave  further  stimulus  to  investigation,  especially  regarding  the 
character  of  the  dejecta.  Nothnagel  suggested  the  name  "mucous 
colic,"  in  order  to  show  that  a  true  enteritis  need  not  exist.  Mucous 
colic  is,  therefore,  an  entity,  and  may  be  defined  as  a  "condition 
characterized  by  the  excessive  production  of  mucus  in  the  colon,  by 
attacks  of  painful  spasms  of  varying  degrees  of  severity  and  fre- 
quency, accompanied  or  followed  by  the  expulsion  of  mucus  in 
gelatinous  masses,  or  in  the  form  of  tubular  casts,  or  in  tape-like 
pieces  or  strings,  and,  furthermore,  characterized  by  anomalies  of  the 
gastro-intestinal  functions  and  by  various  nervous  symptoms." 

Age  and  Sex. — It  is  a  comparatively  rare  affection,  occurring  most 
frequently  in  women  from  twent)^  to  forty,  frequently  in  middle  life. 
A  few  cases  occur  late  in  life  and  rarely  in  children.  Boas  reports 
one  in  early  infancy.     About  75  to  85  per  cent,  occur  in  women. 

Etiology. — Space  will  allow  me  to  mention  only  a  few  of  the  chief 
investigators.  Among  the  various  theories  regarding  the  etiology, 
we  may  mention  the  following: 

1.  Neurasthenia  is  the  prime  factor — mucous  colic  is  a  secretory 
neurosis.  Among  the  advocates  of  this  view  are  notably  DaCosta, 
Siredy,  and  W.  Mendelson,  of  New  York  City. 

2.  The  anatomic  origin.  Kwald  lays  stress  on  ptosis  of  the  colon; 
Boas,  on  atony;  Glenard,  on  splanchnoptosis. 

3.  Partly  nervous  and  partly  anatomic  origin.     Mathieu  considers 


NERVOUS    DISEASES    OF    THE    INTESTINES  673 

it  a  hypersecretion  of  mucus  in  patients  of  a  neuro-arthritic  type,  who 
suffer  from  enteroptosis,  intestinal  sand  being  present.  Hemmeter 
believes  that  often  there  is  some  connection  with  arthritis.  Von 
Noorden  lays  stress  on  long-continued  constipation  in  nervous  sub- 
jects. Einhorn  places  it  among  the  neuroses,  but  finds  that  it  is 
associated  in  many  cases  with  Glenard's  disease  (with  gastroptosis  and 
enteroptosis),  and  that  achylia  gastrica  is  present  in  many  patients. 

4.  Tumors,  adhesions,  enlarged  prostate,  and  various  other  fac- 
tors are  given.  J.  P.  Tuttle  believes  mucous  colic  due  to  organic 
causes.  Roger  traces  the  cause  to  the  liver,  believing  there  is  an  an- 
ticoagulant in  healthy  bile,  and  when  its  production  is  interfered 
with  by  visceral  ptosis,  abnormal  accumulation  of  mucus  begins. 

Nepper^  also  imputes  the  condition  to  disturbance  of  the  biliary 
functions. 

Pathology. — Necropsies  are  rare  unless  death  results  from  some 
intercurrent  disease.  Autopsies  in  the  cases  of  O.  Rothmann,  Osier 
(Edwards),  and  Weigert  demonstrate  that  no  inflammatory  condi- 
tion existed  in  the  colon.  There  was  simply  hypersecretion  of  mu- 
cus. The  consensus  of  opinion  is  that  no  inflammation  exists.  On 
the  other  hand,  M.  Rothmann  reports  i  case  and  Hemmeter  2  cases 
in  which,  in  addition,  some  catarrhal  inflammation  was  present. 
Nothnagel  explains  this  unquestionably  b}^  the  fact  that  there  are 
two  classes  of  cases,  one  in  which  there  is  the  pure  "mucous  colic," 
with  hypersecretion  of  mucus;  and  the  second  class,  in  which  the 
mucous  colic  is  engrafted  on  a  catarrhal  colitis.  I  have  noted,  in  my 
own  experience,  that  the  catarrhal  colitis  may  be  of  such  a  mild  type 
that  attention  may  readily  be  diverted  from  it  on  account  of  the 
predominance  of  the  symptoms  of  the  mucous  colic. 

The  mucus  may  be  passed  in  the  form  of  long,  thin  bands,  ribbon- 
like or  in  the  shape  of  a  tapeworm ;  they  may  be  tubular  or  form  a 
cast  of  the  intestines;  in  some  cases  these  are  of  considerable  length, 
several  feet;  the  mucus  may  be  in  jelly-like  masses  or  even  in  shreds, 
occasionally  streaked  with  blood.  This  discharge  should  be  carefully 
differentiated  from  fascia,  tendons,  the  membranes  of  oranges,  etc. 
After  first  treating  with  subHmated  alcohol  and  then  staining  with 
Ehrlich's  triacid  solution,  a  green  color  occurs  with  mucus,  of  which 
this  discharge  consists;  with  fibrin  it  turns  red.  The  color  of  the 
membranes  in  mucous  colic  is  ordinarily  grayish,  though  they  may 
be  translucent  or  even  transparent.  IMicroscopically,  the  membrane 
consists  of  a  structureless  matrix,  with  columnar  epithelium  scat- 
tered therein ;  its  chief  constituent  is  mucus. 

Symptoms. — These  patients  are  markedly  neurasthenic  and 
morbidly  self-conscious;  in  appearance  they  are  usually  emaciated, 
with  a  history  generally  of  considerable  loss  of  weight.  There  has 
been  obstinate  constipation  of  long  duration,  with  an  occasional  in- 

1  Mucomembranous  Colitis,  its  Causes  and  Mechanism,  New  York  Medical 
Journal,  May  23,  1908. 

43 


674 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


termittent  diarrhea.  Palpitation,  dizziness,  disturbances  of  the 
genito-urinary  system,  hysteric  symptoms,  anemia,  headache,  and 
gastric  disturbances  of  various  types  are  present. 

On  palpation  of  the  abdomen  sensitive  points  will  often  be  de- 
tected. Patients  give  a  history  of  a  sudden  attack  of  acute  abdom- 
inal pain  like  severe  colic,  and  the  abdomen  ma}^  become  swollen  and 
tense.  At  this  time  the  nervous  symptoms  become  extremely  aggra- 
vated. Finally,  the  passage  of  the  mucous  masses  described  occurs 
spontaneously,  with  great  straining  or  with  artificial  aid.  These 
attacks  occur  with  varying  frequency  and  severity.     Between  the 

attacks  the  nervous  conditions  of  the 
patient  may  be  slightly  improved.  This 
is  the  type  of  uncomplicated  (pure)  mu- 
cous colic. 

Nothnagel  describes  a  second  type  of 
enteritis  membranacea  which  is  engrafted 
on  a  colitis.    He  notes  two  classes  of  cases : 

(a)  That  in  which  the  severe  cramp- 
like attacks  are  absent;  the  patient  passes 
mucus  continuously,  with  occasional  tube- 
casts — a  cystic  colitis(Abercrombie's  case), 
as  shown  at  autopsy.  This  is  not  a  true 
mucous  colic. 

(b)  A  class  in  which  mucous  colic  is 
engrafted  on  a  chronic  catarrhal  colitis 
— the  latter  due  in  this  case  to  adhesions 
from  recurrent  appendicitis.  There  were 
small  amounts  of  mucus  passed  at  fre- 
quent intervals  with  occasional  attacks 
of  mucous  coUc.  Operation  relieved  both 
conditions  at  first,  but  the  mucous  colic 
later  returned. 

I  have  had  such  a  patient  under  treat- 
ment; the  appendix  had  been  removed 
and  adhesions  broken  up.  The  patient 
improved  for  a  time,  but  later  relapsed.  I 
found  enteroptosis  associated  with  gastro- 
ptosis.  I  applied  Rose's  belt  and  instituted  treatment.  Improve- 
ment immediately  followed,  with  ultimate  cure. 

Researches. — For  some  years  the  author  has  carried  on  investi- 
gations in  gastroptosis  and  enteroptosis  at  the  Manhattan  State 
Hospital,  as  well  as  other  institutions,  and  also  into  the  etiology  of 
mucous  colic,*  and  he  is  thoroughly  convinced  that  enteroptosis  is  a 
factor  in  mucous  colic. 

In  Fig.   233  is  illustrated  ptosis  of  the  colon,  narrowed  at  one 
point  and  sacculated  above  this.    Gastroptosis  is  associated  with  it. 
1  American  Medicine,  vol.  ix,  No.  9,  pp.  349-354,  March  4,  1905. 


Fig.  233. — Mucous  colic: 
Presence  of  gastroptosis  (G) 
even  of  a  mild  degree,  as 
demonstrable  by  gastrodi- 
aphany  shows  enteroptosis 
(E)  is  present  also;  enter- 
optosis with  sacculation  and 
narrowing  at  ST;  passive 
congestion  and  mucus  accu- 
mulation occurs  in  enlarged 
(sacculated)  portion  of  colon; 
mucous  colic  attacks  occur  as 
result. 


NERVOUS    DISEASES    OF   THE    INTESTINES  675 

This  misplacement  of  the  colon  undoubtedly  favors  circulatory  and, 
hence,  secretory  changes  in  the  sacculated  portion  of  the  colon. 
Fecal  accumulation  is  also  favored,  a  further  cause  of  irritation. 
Absorption,  with  resulting  auto-intoxication  and  nervous  disturb- 
ances following  the  same,  can  thus  readily  result.  Naturally,  a  patient 
of  nervous  temperament,  and  there  are  undoubtedly  many  such,  may 
be  more  markedly  affected,  but  I  do  not  believe  that  neurasthenia 
per  se  will  cause  that  peculiar  entity  known  as  mucous  colic  any  more 
than  it  will  cause  gonorrhea.     There  must  be  other  factors. 

We  know  that  mucous  colic  occurs  in  Glenard's  disease,  that 
Bwald  believes  that  ptosis,  and  Boas  that  atony,  of  the  colon  are 
important  factors,  and  Einhorn  finds  a  large  percentage  of  patients 
with  mucous  colic  that  have  enteroptosis  associated  with  gastropto- 
sis  and  achylia  gastrica. 

I  believe  that  mucous  colic  has  as  its  chief  etiologic  factor  ptosis 
of  the  colon  with  associated  gastroptosis. 

I  have  had  under  observation  a  patient  with  typic  attacks  of 
mucous  colic  which  began  one  month  after  confinement.  She  had 
enteroptosis  and  gastroptosis  (Landau's  disease)  due  to  insufficient 
support  of  the  abdomen  after  the  birth  of  her  child.  She  was  not 
neurasthenic,  and  was  only  nervous  at  the  time  of  her  attack. 

A  specimen  of  the  mucus  passed  by  this  patient  was  about  12 
inches  long,  flat,  and  tape-like,  and  gave  the  typic  reaction  to  the 
mucin  test;  no  fibrin  was  present.  To  my  knowledge,  this  is  the  first 
case  of  mucous  colic  that  has  been  reported  without  the  usual  accom- 
paniment of  neurasthenia,^  and  it  substantiates  my  views.  In  addition, 
in  9  cases  of  mucous  colic  which  I  have  carefully  examined  since  I 
began  these  special  investigations,  I  have  found  in  every  case  varying 
degrees  of  gastroptosis  with  its  associated  enteroptosis. 

In  4  cases  there  was  hyperacidity;  2  cases,  anacidity;  3  cases, 
achylia  gastrica.  Since  the  publication  of  the  above  article  the 
author  has  investigated  many  more  cases,  all  of  which  substantiated 
this  view. 

In  the  newborn  and  in  young  children,  in  whom  several  cases  of 
mucous  colic  have  been  reported,  neurasthenia  surely  cannot  be 
claimed  as  a  cause  of  the  condition.  As  before  stated,  visceral  ptosis 
may  be  present  and  the  patient  be  in  perfect  health;  but  some  con- 
tributory factor,  local  irritation,  anemia,  or  intercurrent  disease  may 
destroy  the  equiUbrium,  and  gastro-intestinal  disturbances,  constipa- 
tion, etc.,  may  result,  and  finally,  mucous  colic.  On  the  other  hand, 
gastro-intestinal  ptosis  may  be  brought  about  by  loss  of  weight  or 
other  factors  mentioned  under  Etiology  of  Gastroptosis,  and  mucous 
colic  finally  result.  Enteroptosis  is  not  invariably  productive  of 
mucous  colic,  any  more  than  is  typhoid  always  complicated  by  hem- 
orrhage or  perforation. 

Enteroptosis  with  associated  gastroptosis  with  gastro-intestinal 
1  Medical  News,  Aug.  6,  1904;  American  Medicine,  March  4,  1905. 


676  DISEASES    OP   THE    STOMACH    AND   INTESTINES 

disturbances  I  consider  factors  in  the  production  of  mucous  colic,  and 
the  neurasthenia  the  result  of  auto-intoxication.  In  effect,  it  may  be 
considered  as  one  of  the  manifestations  of  Glenard'  s  disease.  Other  con- 
tributory factors,  such  as  rectal  irritation,  associated  colitis,  etc.,  will  be 
referred  to  under  Treatment.  In  a  paper  entitled  "A  Consideration  of 
the  Etiology  of  Mucous  Colitis,"  by  John  A.  Lichty,^  there  are  reported 
2 1  cases  of  mucous  colitis ;  ptosis  of  the  viscera  was  demonstrated  in  16 
cases;  the  other  patients  were  seen  before  the  author's  attention  had 
been  directed  to  splanchnoptosis.  He  states  that  it  is  a  well-known 
fact  that  not  infrequently  during  the  examination  of  a  patient  a  con- 
dition of  ptosis  is  found  without  any  symptoms  referring  to  it.  In 
such  cases  there  has  been  established  what  may  be  called  a  condition 
of  perfect  compensation,  and  physiologic  function  has  not  been  dis- 
turbed. When,  however,  this  compensation  is  lost  or  disturbed,  the 
symptom-complex  of  mucous  colitis  appears.  He  notes  a  lithemic 
condition  in  several  patients — notably  one  having  had  several 
attacks  of  acute  articular  rheumatism.  The  gastric  secretion  was 
studied  in  8  patients — in  4  it  was  hyperacid;  in  2,  normal;  in  i, 
hypo-acid,  and  in  i  achylic. 

Prognosis. — These  cases  require  tact  and  patience,  and  most  of 
them  are  of  long  duration.  With  perseverance,  I  believe  them  to  be 
curable. 

Treatment. — This  may  be  summarized  as  follows:  During  the 
attack,  rest  in  bed;  the  application  of  heat  to  the  abdomen  by 
flaxseed  poultices,  turpentine  stupes,  or  hot  pepper  poultices — oj 
(4.0)  red  pepper  to  Oj  (500  cc.)  of  boiling  water — a  flannel  being 
Avrung  out  therein,  covered  with  oiled  silk,  and  applied  to  the  abdo- 
men. Dry  heat,  by  means  of  a  hot-water  bag,  salt-bag,  or  light 
tinplate  (pie  plate),  heated  in  the  oven  and  covered  with  flannel,  may 
be  employed.  Spice  poultices  are  of  service.  Moist  heat,  however, 
seems  best. 

The  greatest  relief  to  the  cramps  and  bearing-down  pains  is 
afforded  by  enteroclysis  by  recurrent  irrigation  with  normal  saline 
solution  at  110°  to  120°  F.,  oil  of  peppermint,  Tllv  to  xv  (0.296- 
0.888)  to  the  quart  (liter),  may  be  added.  Several  gallons  should  be 
employed  once  or  twice  in  twenty-four  hours,  and  no  fluid  should  be 
left  in  the  bowel  after  irrigation,  lest  further  cramps  ensue.  High 
enemata  of  warm  olive  oil — i  pint  to  i  quart  (500  cc.  to  i  liter) — 
are  also  of  service,  as  they  aid  in  relieving  spasm  just  as  does  the 
internal  administration  of  olive  oil  in  spasm  or  stenosis  of  the  pylorus. 
Hot  saline  rectal  injections  containing  oij  to  iv  (60.0-125.0)  of  milk 
of  asafetida  may  be  employed. 

Diet.— Fluid  diet,  milk,  broths,  soups,  etc.,  should  be  enjoined 
during  an  acute  attack. 

Medication. — Tincture  of  belladonna  in  doses  of  TTLx  (0.592  cc.) 
every  three  or  four  hours,  and  pushing  even  to  physiologic  symp- 
1  American  Medicine,  Aug.  6,  1902. 


NERVOUS    DISEASES    OF    THE    INTESTINES  677 

toms,  has  given  me  the  best  results  in  the  treatment  of  spasm. 
Occasionally  it  may  be  necessary  to  employ  codein  in  .016  to  0.03  gm. 
(i~i  gr.)  doses,  or  even  morphin,  0.008  to  0.016  gm.  {^l  gr.),  in  con- 
ditions of  extreme  pain.  If  the  acute  attack  is  rather  prolonged,  the 
internal  administration  of  valerianates  or  of  asafetida,  and  the  addi- 
tion of  milk  of  asafetida  to  the  enema  may  prove  to  be  of  value. 

Between  attacks  I  apply  proper  abdominal  support.  For  this 
purpose  a  silk  elastic  abdominal  supporter,  the  Van  Valzah-Hayes 
support,  Gallant's  or  La  Grecque  corset,  or  Rose 's  adhesive  plaster 
belt  can  be  used.  Rose's  belt  has  the  advantage  of  simplicity  and  it 
cannot  slip  or  become  displaced. 

My  great  object  is  to  "  put  on  fat "  in  all  cases,  and  as  ptosis  of  the 
colon  and  of  the  stomach  are  great  factors  in  the  disease,  the  increase 
of  intra-abdominal  tension  should  be  secured  by  this  means.  The 
belt  is  an  aid  in  the  relief  of  the  functional  disorders  of  the  stomach 
incident  to  the  gastroptosis.  If  the  patient  objects  to  the  plaster, 
then  the  silk  abdominal  supporter  may  be  employed.  In  exceptional 
cases  it  may  be  necessary  to  resort  to  the  rest  cure,  associated  with 
hydrotherapy  and  electrotherapeutics.  Under  such  conditions  we 
may  increase  the  weight  by  following  out  Russell's  method,  such  as 
he  first  instituted  at  the  Post-Graduate  Hospital  in  the  treatment  of 
tuberculosis.  It  was  advocated  by  me  in  cases  of  gastroptosis.  Re- 
garding the  constipation,  the  Kiissmaul-Fleiner  method  of  injecting 
into  the  rectum  nightly  or  every  other  night  warm  olive  oil,  to  be 
retained  all  night,  is  of  great  value.  At  the  beginning  one  may  em- 
ploy a  few  ounces,  increasing  it  to  i  pint  (500  cc.)  or  even  i  quart 
(liter).  The  patient  should  be  taught  regular  habits  in  attempting 
bowel  movement.  A  glass  of  hot  or  cold  water  administered  an  hour 
before  breakfast  is  valuable  as  an  adjunct.  Fluidextract  of  cascara 
sagrada  or  the  compound  cascara  tablets  have  been  found  serA'iceable, 
and  in  some  cases  sodium  phosphate  administered  in  the  morning  is 
of  value.  Other  remedies,  as  suggested  under  Chronic  Constipation, 
can  be  employed.  A  thorough  bowel  action  should  be  secured  daily. 
Massage  of  the  bowel  may  be  emplo}'^ed,  massage  with  a  cannon- 
ball,  or  vibratory  massage.  Sensitive  areas  must  be  avoided.  These 
methods  can  be  used  while  Rose 's  belt  is  -z'n  situ. 

Enteroclysis  several  times  a  week  with  normal  saline  solution  is 
useful,  since  it  promotes  intestinal  peristalsis,  prevents  the  accunui- 
lation  of  mucus,  and  lessens  the  chances  of  spasmodic  attacks.  With 
obstinate  constipation  electric  saline  enteroclysis  is  of  value.  In  addi- 
tion I  sometimes  employ  baths,  abdominal  compresses,  and  electricity. 

The  carbonic  acid  bath  (Nauheim)  is  of  value  in  improving  the 
circulation.  For  the  nervous  conditions  the  same  bath  (Triton 
salts)  has  proved  of  service.  Achilles  Rose  has  devised  a  simple 
method  for  administering  the  dry  gas  bath  without  the  patient 
being  obliged  to  disrobe  (I'ig.  234). 

The  tank  is  filled  with  gas  and  the  patient  sits  therein.    The  height 


678 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


to  which  the  gas  rises  is  estimated  by  means  of  a  burning  candle, 
which  goes  out  when  the  gas  reaches  that  point. 

I  have  secured  at  least  one  brihiant  result  in  the  treatment  of 
mucous  coUc  by  inflation  of  the  colon  with  CO2  gas,  as  advocated  b}- 
Dr.  Rose.  The  method  seems  in  some  cases  to  improve  the  local  cir- 
culatory conditions  in  the  colon,  just  as  it  affects  the  peripheral 
circulation  when  the  bath  is  given.  I  believe  it  worthy  of  trial  as  an 
adjunct  to  the  other  treatment. 

It  merely  requires  a  bottle  with  a  large  mouth.  A  glass  tube 
passes  through  the  cork.    To  this  tube  is  attached  a  piece  of  rubber 


Fig.  234  — Rom.  -  i1i\ 


tubing  with  a  rectal  tip.  From  oss  to  j  (2.0-4.0)  each  of  bicarbonate 
of  soda  and  tartaric  acid  are  placed  in  the  bottle,  w^hich  is  then  filled 
two-thirds  with  water.  The  COo  gas  is  thus  generated,  and  the  bottle 
being  elevated  slightly  above  the  rectum  the  gas  is  allowed  to  flow  in 
until  slight  distention  is  observed.  This  procedure  can  be  carried  out 
every  other  day.     Rose's  CO2  bottle  is  illustrated  in  this  volume. 

I  have  referred  to  certain  mixed  cases  in  w^hich  there  was  a 
catarrhal  colitis  with  a  mucous  colic  later  engrafted  upon  it.  Among 
such  we  can  classify  those  that  may  apparently  be  caused  by  excess- 
ive bicycling  or  horseback  riding,  enlarged  prostate,  uterine  fibroids, 
adhesions  from  appendicitis,  etc.     In   some   of  these   conditions  a 


NERVOUS   DISEASES   OF   THE   INTESTINES  679 

local  congestion  of  the  rectum  or  sigmoid  can  be  detected,  and  careful 
investigation  will  demonstrate  that  the  attack  first  starts  as  a  simple 
proctitis  or  colitis.  Constipation  has  been  previously  present.  Subse- 
quent auto-intoxication,  nervous  symptoms,  and  mucous  colic  result. 
I  believe  that  careful  examination  will  reveal  that  these  patients  have 
had  an  existing  ptosis  of  stomach  and  colon,  quiescent,  with  no  result- 
ing symptoms,  but  as  a  result  of  irritation  causing  favorable  con- 
ditions, mucous  colic  develops.  The  correction  of  such  sources  of 
irritation  is  undoubtedly  rational,  and  will  thus  readily  explain  the 
improvement  which  at  all  times  occurs  after  operative  procedure, 
as  in  the  chronic  appendicitis  case  with  colitis  and  mucous  colic  pre- 
viously described.  The  existence  of  the  "mixed  cases"  will  un- 
doubtedly "clear  up"  the  hitherto  apparently  diverse  opinions  as 
regards  the  etiology  of  this  disease. 

In  such  cases,  with  a  coexisting  catarrhal  colitis,  irrigation  with 
nitrate  of  silver,  1.3  to  2  gm.  (20-30  gr.)  to  2  quarts  of  water,  and 
followed  by  saline  solution,  or  with  resorcin,  .65  to  1.3  gm.  (10-20  gr.) 
in  2  quarts,  or  with  Hsterin,  borolyptol,  glycothymohn,  4  to  8  gm. 
(1-2  dr.)  to  2  quarts,  or  with  gomenol,  4  gm.  (i  dr.)  in  the  same  quan- 
tity of  water,  may  prove  to  be  of  service.  I  have  often  found  entero- 
clysis  with  demulcents,  such  as  weak  flaxseed  tea,  or  185  to  250  cc. 
(6  to  8  oz.)  of  a  saturated  solution  01  gum-arabic  added  to  2  quarts 
(liters)  of  warm  water,  of  value. 

In  pure  mucous  coUc  I  employ  only  normal  saline  solution  or  the 
demulcents  for  removal  of  the  mucus,  since  the  condition  is  due  to 
hypersecretion  and  not  to  inflammation.  I  should  avoid  silver  irri- 
gations in  such  cases,  since  I  have  already  referred  to  the  fact  that 
irrigations  of  silver,  tannin,  alum,  etc.,  can  produce  an  artificial 
hypersecretion.  Small  doses  of  olive  oil  or  of  castor  oil,  in  capsules, 
seem  of  value  for  constipation,  and  improve  the  tone  of  the  mucous 
membrane  of  the  intestines,  providing  they  do  not  increase  the 
patient's  dyspeptic  symptoms. 

Extract  of  nux  vomica,  gr  \  (0.016),  or  strychnin,  gr.  Vo  (coo  108) 
t.  i.  d.,  is  of  ser\dce  in  increasing  the  tone  of  the  gastro-intestinal 
tract  and  the  general  muscular  system.  Resorcin,  5  gr.  (0.3),  or 
sodium  benzoate,  5  to  10  gr.  (0.3-0.6),  or  bismuth  salicylate,  5  to 
10  gr.  (0.3-0.6),  should  be  given  if  there  is  much  gastro-intestmal 
fermentation.  The  use  of  the  following,  suggested  by  W.  H.  Thomson 
in  the  mixed  cases  for  the  treatment  of  catarrh,  gives  good  results: 

I^.     Silver  nitrate 0-32  gm-jgr-  ^') 

Resin  of  turpentine 8.0  gm.  (oij) 

Potash  solution 4-°  gm.  (oj) 

Pulverized  licorice,  q.  s.  to  make  pills  soft. — ]\I. 

Divide  into  60  pills. 
Sig.— Three  pills  t.  i.  d. 

Copper  sulphate,  0.016  (-}  gr.)  t.  i.  d.,  may  be  substituted  later; 

Fowler's  solution  of  arsenic  in  .06  cc.  (TTlj)  dose  t.  i.  d.  has  also  been 

found  useful  in  these  mixed  cases. 


68o  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

General  Treatment. — Exercise  and  outdoor  life,  as  golf,  etc., 
to  strengthen  the  abdominal  muscles,  are  important.  During  winter 
weather  fencing  is  useful.  The  general  nervous  system  must  be 
toned  up  and  anemia  should  be  corrected.  Iron  tropon  is  easy  to 
assimilate.  An  excellent  combination  is  a  fresh  Blaud's  pill  (iron), 
.32  gm.  (5  gr.),  made  soft  with  honey;  in  each  pill  is  incorporated 
tTLij  (0.118)  Fowler's  solution  of  arsenic,  and  extract  of  nux  vomica 
0.008  gm.  (I  gr.),  or  0.00108  gm.  (-g'o  gr.)  of  strychnin.  The  gly- 
cerophosphates or  phosphorus  compounds  are  of  value  for  the  ner- 
vous conditions.  Hydrotherapy,  massage,  and  electrotherapy  may 
be  used. 

Diet. — As  before  noted,  fluid  diet,  milk,  kumyss,  bacillac,  lac- 
tone-buttermilk,  broths,  gruels,  etc.,  with  the  addition  of  somatose 
or  liquid  peptonoids,  should  be  used  during  the  attacks.  Between 
attacks.  Von  Noorden  advocates  a  very  coarse  diet  (bread  containing 
plenty  of  chaff,  vegetables  rich  in  cellulose,  fruits  with  skins,  etc.),  to 
form  ballast  for  the  bowel.  He  claims  excellent  results.  It  is  my 
custom  to  determine  the  condition  of  the  stomach.  Like  Einhorn,  I 
have  found  cases  of  achylia  gastrica  in  mucous  colic,  but  more  cases 
of  hyperchlorhydria  and  a  few  of  hypochlorhydria.  These  special 
conditions  should  be  treated  in  each  individual  case  and  appropriate 
diet  instituted.  Stomachics  and  dilute  hydrochloric  acid  should  be 
given  when  there  is  deficiency  of  HCl,  and  alkalis  if  there  is  hyper- 
acidity (see  Hyperchlorhydria,  Achylia  Gastrica,  etc.).  We  should, 
however,  give  our  patient  abundant  nutrition.  Cod-liver  oil  and  fats, 
such  as  Russell's  emulsion,  cream,  etc.,  are  of  value  when  they  can 
be  assimilated.  The  addition  of  healthy  fat,  with  increase  in  weight, 
means  the  cure  of  our  patient. 

Surgery. — Some  writers,  notably  Hale  White,  have  recommended 
a  right  inguinal  colotomy  to  give  rest  to  the  colon  in  certain  intract- 
able cases.  This  would  not  relieve  the  ptosis,  however.  In  severe 
cases  one  might  resort  to  shortening  the  suspensory  ligaments  of  the 
stomach  and  colon.  Gastropexy  and  colopexy  might  be  performed, 
but  to  my  mind  it  is  always  objectionable  to  suture  a  viscus  to  the 
abdominal  wall.  If  there  is  hepatoptosis,  Elliot 's  operation  for  sup- 
port of  the  liver  might  be  instituted  at  the  same  time.  These  pro- 
cedures will  aid  in  the  support  of  the  floating  kidney  if  such  be  present. 
Nephropexy,  I  believe,  is  rarely  indicated  when  it  is  a  part  of  general 
ptosis,  unless  there  be  some  evidence  of  nephritis  or  interference  with 
its  functions.  Some  recommend  a  "revision"  (tightening)  of  the  ab- 
dominal muscles  (recti)  by  means  of  suturing,  so  as  to  relieve  the 
muscular  relaxation.  This  last  procedure,  as  advocated  by  R.  T. 
Morris,  I  consider  preferable.  I  believe  that  resort  to  surgery  is 
rarely  required  except  in  the  most  obstinate  cases,  and  only  after  at 
least  two  years'  continuous  medical  treatment,  with  failure  to  secure 
cure  or  comparative  comfort  for  the  patient. 


CHAPTER  XXXIII 

INTESTINAL  PARASITES 

Most  of  the  animal  parasites  that  occur  in  mankind  inhabit  the  in- 
testinal canal.  There  are  about  fifty  varieties,  but  all  do  not  produce 
morbid  conditions.  Some  cause  a  pathologic  state  locally  in  the 
intestines  or  by  their  toxins  in  the  blood.  There  are  no  absolutely 
characteristic  symptoms  produced  by  these  parasites,  but  they  are 
detected  by  discovering  either  them  or,  in  the  case  of  worms,  their 
ova  in  the  stools. 

Gastro-intestinal  disturbances,  with  or  without  anemia  and  with 
nervous  symptoms,  may  result  from  their  presence.  There  are  two 
chief  groups — the  protozoa  and  the  vermes. 

Protozoa 

AMEB^ 

In  addition  to  the  dysenteric  amebae  which  have  been  described, 
amebse  differing  sHghtly  in  certain  characteristics  from  the  dysen- 
teric variety  have  been  reported.  They  are  said  to  give  rise  to  no 
symptoms  or  at  times  to  slight  diarrhea.  Musgrave  is  skeptical  as 
regards  the  existence  of  non-pathogenic  amebae. 

SPOROZOA 

Coccidia  are  occasionally  found  in  the  stools.  These  are  egg 
shaped,  provided  with  a  thin  shell,  are  about  0.02  mm.  long,  con- 
taining in  the  interior  a  large  number  of  nuclei,  usually  arranged  in 
groups.     They  do  not  seem  to  have  a  pathologic  bearing. 

INTERNAL  PSOROSPERMIASIS 

Psorosperms  have  been  found  in  the  liver,  spleen,  kidneys,  and 
ileum,  producing  a  disease  similar  to  that  in  rabbits.  One  patient, 
notablv  referred  to  by  Osler,^  was  thought  to  be  suffering  from  typhoid 
fever.  The  patient  had  diarrhea  and  enlarged  liver  and  spleen.  Masses 
resembling  tubercles  in  the  liver,  spleen,  and  ileum  were  found  to  con- 
tain coccidia. 

INFUSORIA 

Cercomonas  intestinalis  is  pear  shaped,  has  a  distinct  nucleus, 
and  eight  flagellar    The  head  tapers  obliquely  and  has  a  depression 

1  Practice  of  Medicine,  1906. 

681 


682 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


(Fig.  235).      It  is  believed  that  this    organism  is  Hable  to  prolong 
existing  catarrhal  affection  of  the  intestines. 

Trichomonas  intestinalis  is  distinguished  from  the  former  by  its 
greater  size  and  the  row  of  fine  cilia  on  its  periphery  (Fig.  236). 
In  fresh  dejecta  it  shows  active  movements.  Zunker^  reports  it  in 
mushy  dejecta  of  yellowish-brown  color  and  putrid  odor. 


Fig.  235. — Cercomonas  intestinalis:  A,  Larger,  B,  smaller,  variety  (Davaine). 

Balantidimn  (Paramcecium)  Coli. — The  body  is  oval  shaped, 
measuring  from  0.07  to  o.i  mm.  in  length,  by  0.05  to  0.07  mm.  in 
breadth  (Fig.  237).  The  anterior  end  is  slightly  truncated,  with  a 
short  peristome,  generally  funnel  shaped,  and  opens  externally  near 
the  anterior  pole.    When  feeding  it  opens  out  and  broadens,  so  one 


Fig.  236. — Trichomonas  intestinalis  (after  Zunker). 


can  see  it  is  a  mouth  which  leads  to  a  gullet  and  not  a  simple  furrow. 
The  left  border  has  long  cilia,  while  the  rest  of  the  mouth  is  desti- 
tute of  them.  The  surface  of  the  cortical  layer  is  surrounded  by  a 
cuticle  covered  with  cilia.  The  interior  structure  consists  of  granu- 
lar substance.    It  contains  a  nucleus  and  contractile  vacuoles. 

Fat  and  starch  granules  and,  occasionally,  red 
and  white  corpuscles  may  be  found  within  the  gran- 
ular substance.  The  posterior  end  is  rounded  and 
contains  the  anus.  Particles  may  be  obser\^ed  to 
pass  from  it.  The  parasite  can  change  its  shape 
and  possesses  both  forward  and  rotary  motion. 
Reproduction  occurs  by  division,  budding,  and  con- 
jugation. 

The  balantidium  is  a  parasite  of  the  colon  and 

cecum  of  the  hog.    Human  infection  probably  occurs 

most  frequently  through  the  infusorium  entering  its 

host  in  the  encapsulated  state.     When  hog  feces  are  , 

dried  and  broken  up,  the  encysted  forms  are  scattered  about  and  come 

in  contact  with  the  food  or  drinking-water.    The  parasite  has  been 

found  in  the  city  of  London  in  the  drinking-water.    The  disease  f re- 

1  Deutsche  Zeitschr.  f.  Praktish.  Medicin,  1878,  No.  i. 


Fig.  237.- 
lantidium 
(Malmsten) 


INTESTINAL   PARASITES 


683 


quently  occurs  after  the  preparation  of  sausage  or  the  ingestion  of 
uncooked  sausage-meat.   Malmsten  first  described  the  disease  in  1857. 


<^ 


0f 


<*• 


Fig.  238. — Balantidium  coli:   Parasite  more  highly  magnified,  showing  flagella 

(Strong). 

Musgrave  has  written  on  the  subject,  and  for  the  most  complete 
description  the  reader  should  refer  to  R.  P.  Strong's^  article,  "The 


Fig.  239. — Balantidium  coli:  A  parasite  passing  through  the  walls  of  a 
gland  of  Lieberkiihn,  rupturing  the  basement  membrane.  The  parasite  shows 
the  striation  referred  to  in  the  text  (Strong). 

Clinical  and  Pathologic  Significance  of  Balantidium  Coli."    He  tabu- 
lates 117  cases. 

1  Bureau  of  Government  Laboratories,  Manila,  No.  26,  Dec,  1904. 


684 


DISEASES    OF   THE    STOMACH    AND   INTESTINES 


The  balantidia  frequently  exist  alone,  though  sometimes  other 
parasites,  such  as  Bothriocephalus  latus,  Ascaris  lumbricoides,  Tri- 
chocephalus  dispar,  etc.,  may  be  associated. 

Harlow  Brooks  ^  found  balantidia  the  cause  of  an  epidemic  of 
diarrhea  among  the  orang-outangs  in  the  New  York  Zoological  Park. 
The  lesions  found  in  human  beings  seem  to  be  an  ulcerative  colitis 
(Figs.  238-240),  with  the  infection  in  the  large  intestine.  In  some 
cases  there  were  swelling  of  the  lymphatics  of  the  mesentery  and 
mesocolic  glands  and  chronic  adhesive  peritonitis.  Pulmonary,  car- 
diac, renal,  and  cerebral  complications  may  occur. 

Symptoms. — The  presence  of  Balantidia  coli  in  the  stools  is  usu- 
ally associated  with  diarrhea ;  the  feces  are  liquid,  often  contain  mucus, 
sometimes  undigested  food,  and  frequently  blood.     Diarrhea  is  per- 


Fig.  240. — Balantidium  coli.  The  early  lesions  of  the  mucosa,  consisting  of 
desquamation  of  epithelial  cells  of  the  glands,  round-celled  infiltration,  etc. 
About  a  dozen  parasites  may  be  counted  in  this  field   (Strong). 

sistent  until  treatment  is  directed  against  the  parasite.  Colic  is  fre- 
quent, nausea  and  vomiting  may  occur.  The  abdomen  may  be  swollen. 
It  is  often  painful  on  pressure  along  the  colon,  and  on  palpation 
the  latter  may  feel  thickened.     Tenesmus  is  common. 

In  chronic  cases  there  are  weakness,  exhaustion,  and  emaciation; 
more  or  less  anemia  and  edema  of  the  feet  and  ankles. 

In  the  fresh  stools  the  balantidia  move  about  rapidly,  but  die  in 
from  one-half  hour  to  two  hours  after  the  dejecta  have  been  passed. 

Only  2  cases  are  reported  in  children;  25  per  cent,  of  cases  give 
the  history  of  association  with  or  caring  for  pigs  or  having  eaten  or 
prepared  fresh  sausage. 

Eosinophilia  is  present  locally  in  the  intestines  and  also  in  the 

1  New  York  University  Bulletin  nf  Medical  Sciences,  Jan.,  1902. 


INTESTINAL  PARASITES  685 

blood.  The  temperature  may  be  subnormal  or  at  times  of  consider- 
able height. 

The  disease  has  been  found  in  Germany,  Sweden,  Russia,  France, 
the  United  States,  and  the  Philippines.  Balantidia  probably  occur 
more  frequently  than  we  suppose. 

The  mortahty  was  30  per  cent.,  but  depended  somewhat  on  the 
presence  of  other  diseases  which  were  associated  in  many  of  the  fatal 
cases  reported.  In  33  per  cent,  there  were  cures,  and  improvement  in 
the  other  cases. 

Treatment. — The  following  solutions  for  topical  irrigations  or 
enemata  have  been  suggested : 

Ems'  salt,  by  water  enemata,  gx.  15  (i.o)  are  added  to  1500  cc. 
(ij  quarts)  of  water,  followed  by  quinin  enemata,  i  quart  (Hter)  of 
1 :  750  or  1 :  500  strength. 

Others  suggest  calomel,  gr.  2  (o.i)t.  i.  d.  for  two  days  only,  or 
naphthalin,  gr.  5  (0.3)  t.  i.  d.,  daily  by  mouth,  with  tannic  acid,  3j 
(4.0)  to  Oj  (500  cc.)  of  water,  by  injection,  every  day. 

Acetic  acid  enemata — acetic  acid,  gr.  50  (3.3)  to  2  quarts  (liters) 
of  water  at  37°  C. — once  or  twice  a  day,  with  tannic  acid,  gr.  5  (0.3) 
t.  i.  d.,  by  mouth,  proved  useful  in  some  cases. 

Another  combination  is  salicylic  acid,  gr.  15  (i.o),  and  sodium 
sulphate,  oss  (16.0),  morning  and  night,  by  mouth,  with  enemata  twice 
a  day  of  salicylic  acid  (i :  1000),  or  salol,  by  mouth,  gr.  5  (0.3),  four  or 
five  times  a  day,  with  salicylic  acid  (i :  1000),  or  boracic  acid  enemata 
5j  (4.0)  to  the  quart  (liter)  of  water,  are  suggested. 

Sodium  bicarbonate  (2  per  cent.)  enemata,  followed  by  a  salicylic 
acid  (i  :2ooo  to  i :  1000)  enema,  with  salol,  gr.  5  (0.3),  and  tannalbin, 
gr.  5  to  10  (0.3-0.6),  by  mouth,  each  several  times  a  day,  have  given 
good  results. 

Thymol  (i :  2500),  acetozone  (i :  1000),  quinin  bisulphate  (i :  500), 
administered  by  enema  or  irrigation,  as  in  dysentery,  with  the  use  of 
salol  and  tannin  preparations  by  mouth,  are  valuable. 

One  might  also  administer  small  quantities  of  acetozone  (1:1 000) 
by  mouth. 

Vermes 

Cestodes  (Tapeworms) ;  Hydatid  Disease. — The  adult  para- 
sites live  in  the  small  intestine  of  man;  the  larv^al  forms,  in  the  mus- 
cles and  other  organs. 

The  most  important  varieties  of  tapeworms  found  in  human 
beings  are  the  Taenia  solium.  Taenia  mediocanellata,  and  the  Bothrio- 
cephalus  latus. 

The  symptoms  produced  by  these  varieties  of  tapeworms  are 
about  identical,  except  in  the  case  of  the  bothriocephalus,  which  at 
times  gives  special  symptoms. 

The  parasites  are  found  at  all  ages,  are  not  uncommon  in  children, 
and  occasionally  are  found  in  sucklings.     They  may  cause  no  disturb- 


686  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

ance,  and  one  may  only  learn  of  their  presence  by  noting  segments  of 
the  tenia  in  the  dejecta. 

In  other  cases  there  may  be  general  as  well  as  intestinal  disturb- 
ances. 

There  ma}'  be  pressure  in  the  pit  of  the  stomach,  abdominal  pains, 
ravenous  appetite  (bulimia),  nausea,  at  times  loss  of  appetite,  occa- 
sionally vomiting.  Diarrhea  is  sometimes  present  or  there  may  be 
constipation. 

In  women  and  nervous  patients  we  may  see  mental  depression 
and  even  hypochondria.  There  may  be  dizziness,  headache,  fainting 
spells,  chorea,  convulsions,  and  even  epileptic  attacks.  Some  patients 
may  emaciate,  feel  weak,  and  suffer  from  palpitation. 

The  bothriocephalus  may  cause  a  severe  and  even  fatal  anemia 
(pernicious),  with  poikilocytosis  and  nucleated  red  blood-corpuscles; 
and  with  it  there  may  be  edema  of  the  feet  and  eyelids  and  hemor- 
rhages from  the  mucous  membranes. 

The  metabolic  products  of  this  worm  probably  have  a  hemolytic 
action. 

The  diagnosis  can  only  be  made  by  discovery  of  the  segments  of  the 
parasites  or  their  eggs  in  the  stools. 

General  Description  of  the  Tapeworm. — It  has  a  scolex  or  head, 
which  may  live  for  years  even  when  detached  from  the  rest  of  the  body, 
an  oblong  neck,  and  detachable  segments  (proglottides).  These  last 
vary  in  size  and  shape  and  possess  the  power  of  motion.  The  worm 
is  flat  and  devoid  of  mouth  or  intestines.  It  grows  by  alternate  genera- 
tion through  germination  of  a  pear-shaped  primary  host  (head),  and 
remains  united  to  the  latter  for  a  time  as  a  colony  of  band-like  shape. 
Each  segment  forms  a  sexually  active  individual.  The  proglottides 
gradually  increase  in  size  as  they  become  more  distant  from  the  head, 
and  then  diminish  again  toward  the  extremity.  The  tapeworm  is  an 
hermaphrodite.  On  its  head  are  four  sucking  disks,  by  which  it 
attaches  itself  to  the  mucosa  of  the  intestines.  By  means  of  pores  it 
derives  its  nourishment  from  the  chyme. 

The  older  proglottides  contain  many  fructified  eggs.  These  are 
emptied  at  intervals  into  the  intestinal  canal  and  appear  in  the  dejecta. 
The  ovum  contains  an  embryo,  which  requires  for  its  development  an 
intermediary  host.  After  reaching  the  stomach  the  envelope  is  dis- 
solved by  the  gastric  juice.  The  embryo  is  set  free  and  finds  its  way 
by  the  lymphatics  or  blood-vessels  to  some  place  (usually  the  muscles) 
where  it  settles.  It  here  surrounds  itself  with  a  sac,  which  may  later 
be  surrounded  by  a  calcareous  deposit.  In  this  condition  it  is  called 
a  cysticercus  or  measle.  When  the  measle  reaches  the  stomach  of  a 
new  host  it  opens,  and  its  scolex  enters  into  the  small  intestine,  where 
it  develops  into  a  full-grown  tapeworm. 

Tcznia  Solium. — Armed  tapeworm  or  pork  tapeworm.  This  is  not 
common  to  North  America,  but  more  frequent  in  Europe  and  Asia. 
When  mature  it  is  from  6  to  12  feet  (2-4  meters)  or  more  long.    The 


INTESTINAI.  PARASITES 


687 


head  is  smaller  than  the  head  of  a  pin,  spheric,  and  provided  with  four 
sucking  disks,  in  the  middle  of  which  is  the  rostellum  and  a  double 
row  of  hooklets,  from  twenty-four  to  twenty-six  in  number,  and 
hence  is  called  the  armed  tapeworm  (Fig.  241). 

The  neck  is  narrow  and  thread-like,  nearly  i  inch  long.  The  body 
is  divided  into  segments,  which  possess  both  male  and  female  genera- 
tive organs,  and  at  about  the  four  hundred 
and  fiftieth  they  become  mature  and  contain 
ripe  ova.     The  segments  are  about  i  cm.  in 


Fig.  241 . — Head  of  Taenia  solium,  ros- 
tellum with  hooks;  suckers  (Mosler  and 
Peiper). 


Fig.  242. — Mature  segments  of 
Tsenia  solium;  proglottides;  uterus 
and  branches  (Mosler  and  Peiper). 


length  and  from  7  to  8  mm.  wide.  The  worm  attains  its  full  growth 
in  about  three  to  three  and  a  half  months,  about  which  time  the  seg- 
ments are  continuously  shed  and  appear  in  the  stool.  The  uterus 
forms  a  straight  median  tube  in  each  segment,  giving  off  five  to  seven 
branches  on  each  side.  The  branches  are  undivided  at  first,  but 
finally  ramify  as  a  tuft  (Fig.  242). 


Fig.  243. — Eggs  of  Taenia  solium, 'showing  thick  shell  (Mosler  and  Peiper). 

The  eggs  are  rounded  and  provided  with  a  thick  shell  (Fig.  243). 

Rarely  the  cysticerci  (measles)  are  found  in  man,  as  in  the  mus- 
cles, brain,  eye,  and  skin. 

In  the  muscular  system  they  cause  pain,  numbness,  weakness, 
and  symptoms  a  little  like  peripheral  neuritis.  In  the  ventricles  of 
the  brain  irritative  symptoms  may  result.  In  one  case  diabetic  symp- 
toms were  reported.     They  can  be  recognized  in  the   eye.     Taenia 


688 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


solium  was  formerly  believed  to  exist  alone,  but  several  have  been 
found  together. 

T(Bma  saginata,  or  Mediocanellata,  the  unarmed  or  beef  tapeworm. 

This  is  the  most  common  form  seen  in  America  as  well  as  abroad. 
It  is  longer,  thicker,  and  wider   than  the  Tsenia  solium.      It  may 


Fig.    246.- — Bothriocephalus     latus: 
a,  a,  Head;  b,  neck  (Blanchard). 


Fig.  244. — Scolex  of  Tsenia  saginata 
(Hosier  and  Peiper). 


Fig.   245. — Segments  of  Taenia  sag- 
inata (Mosler  and  Peiper). 


Fig.  247. — Bothriocephalus  latus 
(Eichhorst). 


attain  a  length  of  15  to  20  feet  (approximately  4§  to  6  meters)  or 
more.  The  head  measures  over  2  mm.  in  breadth,  has  four  large  suck- 
ing disks,  but  no  hooklets  and  no  rostellum  (Fig.  244).  It  is  square 
shaped. 


INTESTINAL    PARASITES  689 

The  ripe  segments  are  from  17  to  18  mm.  in  length  and  from  8  to 
10  mm.  in  breadth.  The  uterus  consists  of  a  median  stem,  with  from 
about  twenty  to  thirty-five  lateral  branches  (Fig.  245). 

The  ova  are  larger  and  the  shell  thicker,  and  possibly  slightly 
more  elliptic,  but  the  two  forms  are  difficult  to  distinguish  by  their 
ova.  The  measles  (cysticerci)  occur  in  beef  and  are  smaller  than 
those  of  the  Taenia  solium.  Human  beings  acquire  this  worm  by  the 
consumption  of  raw  beef. 

Bothrwccphalus  Latus  (Taenia  Lata,  or  Pig  Head). — This  is  found 
in  certain  districts  bordering  on  the  Baltic  Sea,  in  Holland,  Switzer- 
land, and  Japan.  A  few  cases  have  occurred  in  the  United  States, 
believed  generally  to  have  been  imported. 

The  parasite  is  large  and  long,  measuring  25  to  30  feet  or,  more 
approximately,  7^  to  9  meters. 

The  head  is  elongated,  almond  shaped,  being  about  2  mm.  long 
and  I  mm.  broad ;  it  has  two  grooves,  probably  suckers,  on  its  flat 
surface  (Fig.  246). 

It  has  no  booklets.     The  neck  is  narrow  and  short,  about  2  cm. 
in  length,  and  passes  at  once  into  the  body  segment.    The  body  is  thin 
and  flat  (Fig.  247).    The  full-grown  proglottides  are  nearly  square  and 
show    the    sexual    organs    in    the 
center. 

The  uterus  presents  as  a  median 
dark  line,  with  four  to  six  lateral 
branches,  looking  like  a  star  or 
rosette.  The  eggs  are  oval,  round, 
wdth  a  thin  membrane  and  a  lid 
(Fig.  248).  They  measure  0.07  mm.  p^^  2lI-Eggs  of  Bothriocephalus 
long  and  0.04  mm.  in   width.     The  latus  (Mosler  and  Peiper). 

larvae  develop  in  the  peritoneum  and 

muscles  of  pike  especially,  and  of  fish  such  as  the  turbot,  perch,  and 
trout.     Infection  occurs  through  eating  insufficiently  cooked  fish. 

Taenia  lata  occur  in  the  small  intestine  of  men  and  rarely  in  dogs. 
A  severe  and  even  fatal  form  of  anemia  may  result  from  this  worm. 

There  are  a  few  rare  forms  of  tapeworms  occasionally  found  in 
human  beings. 

TcBnia  nana  (Hymenolepsis  nana)  occurs  chiefly  in  Italy,  occa- 
sionally in  Egypt.  It  is  the  smallest  tapeworm  found  in  man, 
measuring  10  to  15  mm.  long,  and  may  have  nearly  two  hundred 
segments.  The  head  has  four  sucking  disks,  a  rostellum,  and  about 
twenty-four  booklets  in  a  single  row.  Proglottides  are  short  and 
broad.  It  is  found  more  frequently  in  children,  and  occurs  in  large 
numbers  in  the  small  intestine. 

Nervous  disturbances,  fainting  spells,  and  even  epileptiform  at- 
tacks are  produced  thereby. 

The  Davainea  Madagascariensis  (Taenia  Madagascariensis)  is  a 
rare  form  of  this  worm. 

44 


690  DISEASKS   OF   THE    STOMACH    AND    INTESTINES 

Tcenia  cucumerina  (Elliptica,  or  Dipylidium  Caninum). — This  is 
small,  of  cucumber  shape,  occurs  frequently  in  the  intestines  of  the 
dog,  and  has  been  found  in  small  children.  The  larvae  develop  in  the 
lice  and  flees  of  the  dog.  The  worm  is  10  to  40  cm.  long  and  about 
3  mm.  wide. 

Tcenia  Flavopunctata  (Hymenolepsis  Diminuta). — This  has  been 
met  with  in  about  12  cases.  The  worm  is  2  to  6  cm.  long  and  about 
3  mm.  wide.  Its  head  is  small,  club  shaped,  and  provided  with 
sucking  disks.  It  is  common  in  rats.  The  larvae  develop  in  Lepi- 
doptera  and  in  beetles. 

Bothriocephalus  Cordatus. — This  tapeworm  resembles  the  Bothrio- 
cephalus  latus,  except  that  it  is  shorter  and  the  head  merges  into  the 
proglottides  without  an  intervening  neck.  It  occurs  in  the  intestines 
of  men  and  dogs  in  Greenland. 

Other  types  of  tapeworms  occur,  but  they  are  excessively  rare  and 
not  found  in  Europe  or  America. 

Echinococci  are  the  larvae  of  the  Taenia  echinococcus  of  the  dog. 
The  latter  is  a  tiny  cestode  4  or  5  mm.  long,  consisting  of  three  or  four 
segments,  of  which  the  terminal  one  alone  is  mature.  The  head  is 
small,  provided  with  four  sucking  disks,  and  a  rostellum  with  a 
double  row  of  hooklets. 

As  a  result  of  the  ingestion  of  these  parasites,  cysts  develop  in 
various  parts  of  the  human  organism,  as  in  the  liver,  muscles,  etc. 
These  cysts  contain  scolices,  the  head  of  the  taenia  presenting  four 
sucking  disks  and  a  circle  of  hooklets. 

Cysts  have  been  passed  per  rectum.  The  disease  is  common  to 
Iceland,  not  uncommon  in  Europe,  but  rare  in  this  country.  The 
reader  is  referred  to  Echinococcus  Disease  in  any  work  pn  Practice 
of  Medicine. 

Treatment  of  Tapeworms. — To  escape  infection  avoid  raw, 
medium-done  meats,  pork,  and  fish.  One  should  not  trust  to  meat  in- 
spection alone.  Thorough  cooking  of  the  meat  is  the  only  guaran- 
tee of  extinction  of  the  cysticerci.  All  worms  or  fragments  removed 
should  be  destroyed  by  burning,  and  if  one  handles  the  proglottides 
or  ova,  the  hands  should  immediately  be  disinfected;  also  the  stools. 

For  about  two  days  before  administering  a  vermifuge  the  patient 
should  be  kept  on  a  scanty  diet,  consisting  of  broths,  soups  or  milk, 
with  a  few  crackers.  The  night  before,  no  food ;  and  in  the  morn- 
ing a  cup  of  tea  or  coffee,  followed  in  about  an  hour  by  the  vermi- 
fuge. 

Calomel,  gr.  5  (0.3),  castor  oil,  oss  to  j  (15.0-30.0),  or  a  saline 
cathartic  should  be  given  daily  for  a  couple  of  days  previously. 

Male  fern  is  considered  quite  efficient. 

Extract  of  filix  mas,  ethereal,  3iss  to  iiss  (6.0-10.0),  mixed  with 
simple  syrup;  follow  in  a  couple  of  hours  by  a  saline  cathartic  or 
castor  oil. 

The  following  have  also  been  suggested :  Oleoresin  aspidii  (male 


INTESTlNAIv   PARASITES  69 1 

fern),  ossto  j  (2.0-4.0),  in  capsules,  coated  with  keratin;  a  few  hours 
later  castor  oil,  oj  (30.0). 

Filicic  acid  (filmaron),  an  amorphous  principle  from  root  of  male 
fern,  insoluble  in  water.  It  should  not  be  administered  in  fatty  oils 
or  alcohol,  as  they  dissolve  it  and  it  is  toxic.  Give  in  capsules,  gr. 
viiss  to  XV  (0.5-1.0);  follow  by  a  saline  purgative  (not  castor 
oil). 

Pomegranate  root  is  efficient,  given  as  an  infusion  of  the  hark; 
3  ounces  are  macerated  in  10  ounces  of  water  and  then  reduced  to  one- 
half  by  evaporation.  The  entire  quantity  is  taken  in  divided  doses 
within  an  hour  or  more.  It  is  effective,  though  sometimes  producing 
colic. 

The  active  principle  of  the  root,  peUetierin,  gr.  ivto  viiss  (0.25-0.5), 
in  sweetened  water,  to  which  tannin,  gr.  v  (0.3),  can  be  added,  may  be 
given  as  a  substitute.  These  remedies  are  followed  in  a  couple  of 
hours  by  a  purge.  PeUetierin  tannate  can  be  secured  and  given  in 
the  same  dose. 

Pumpkin  seeds  (Semina  cucurbitae),  3  or  4  ounces  (90.0-125.0), 
should  be  bruised  and  macerated  for  twelve  to  fourteen  hours ;  then 
mixed  with  a  little  grape-sugar,  diluted  with  milk,  Oj  (500  cc),  and 
take  in  two  doses  about  half  an  hour  a  part ;  then  follow  in  two  hours 
by  castor  oil. 

Turpentine,  Oleum  terebinthinae  (spirits  of  turpentine),  oj  (30.0), 
in  honey  or  with  sugar,  follow  with  a  glass  or  two  of  milk;  and  two 
hours  later  a  cathartic. 

I  have  found  pine-needle  oil  (Gardner's),  oj  to  ij  (4.0-8.0),  also 
efficacious.  ' 

Cusso  (kousso),  cusso  pulv.,  oss  (16.0);  mel  depuratum  (honey), 
oss  (16.0). 

Or  cusso  can  be  mixed  with  sugar,  water,  or  lemonade,  and  taken 
in  divided  doses  within  an  hour.  Though  cusso  is  cathartic,  it  is 
preferable  to  follow  in  two  hours  with  a  dose  of  castor  oil. 

Kamala,  pulv.  kamala,  oj  to  ij  (4.0-8.0),  suspended  in  syrup  or  in 
wine.  This  preparation  is  purgative  and  may  cause  griping,  nausea, 
and  vomiting.  The  dose  should  be  distributed  over  an  hour.  Castor 
oil  may  be  given  later. 

Cocoanut  has  been  recommended  as  a  vermifuge ;  the  milk  and 
albumin  of  an  entire  nut  should  be  taken  within  an  hour. 

Naphthalin,  in  capsules,  gr.  10  to  30  (0.6-2.0),  in  divided  doses,- 
within  a  few  hours. 

Salol,  gr.  45  (3.0),  in  capsules,  in  divided  doses,  has  been  recom- . 
mended. 

A  combination  of  these  remedies  is  often  effective.  Thus:  take 
oss  (16.0)  of  an  infusion  of  pomegranate  seeds;  pumpkin  seeds,  oj 
(30.0);  pulv.  ergot,  oj  (4-0),  and  boiling  water  10  ounces  (300  cc. 
approximately).  Make  an  emulsion  of  male  fern — oj  (4.0)  ethereal 
extract  with  acacia  powder.     Mix  the  emulsion   and   infusion  and 


692  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

take  fasting  at  9  a.  m.  Follow  a  couple  of  hours  later  with  castor  oil 
or  a  saline  cathartic. 

Osier  recommends  the  addition  of  croton  oil,  TTlij  (0.118),  to  the 
above,  but  I  think  this  rather  too  active  treatment.  Male  fern, 
pumpkin  seed,  pomegranate,  and  turpentine  are  the  best  remedies. 

About  two  hours  after  the  vermifuge  a  cathartic,  such  as  citrate  of 
magnesia,  3j  to  ij  (4.0-8.0),  or  magnesium  sulphate,  larger  doses,  or 
some  other  saline  cathartic,  or  castor  oil,  o  j  to  ij  (30.0-60.0),  should  be 
given. 

The  head  of  the  tapeworm  should  be  looked  for,  as  the  parasite 
will  regrow  if  this  is  not  removed.  In  some  cases  this  is  difficult 
to  find.  Children  require  proportionately  smaller  doses,  according  to 
their  age.  Care  must  be  exercised  with  patients  who  are  debili- 
tated, recently  convalescent  from  typhoid,  or  have  severe  intestinal 
disorders.     It  may  be  necessary  to  postpone  treatment. 

Trematodes  (Fluke  Worms) ;  Distomiasis. — Flukes  are  found  in 
the  lungs,  liver,  small  intestine,  and  in  the  blood;  in  the  latter  case 
affecting  chiefly  the  urinary  system  and  the  rectum. 


Fig.  249. — Distoma  hepaticum,  with  male  and  female  sexual  apparatus;    X  2^ 

(Leuckart). 

The  trematodes  are  soHd  worms  of  leaf  or  tongue  shape.     They 
possess  a  clinging  apparatus  in  the  form  of  oral  and  ventral  sucking 
cups,  which  vary  in  number.    Sometimes  they  also  have  hook  or  clasp- 
like projections.    The  intestinal  canal  is  without  an  anus  and  is  split 
like  a  fork.    They  are  generally  hermaphroditic. 

Flukes  are  found  in  China,  Japan,  India,  Egypt,  Arabia,  and  Persia, 
and  imported  cases  have  been  found  in  Canada  and  the  United  States. 

They  have  been  found  in  the  cat,  dog,  and  hog  in  this  country. 

Five  species  of  liver  fluke  are  known  to  occur  in  man.  The  Distoma 
conjunctum,  the  Indian  liver  fluke,  usually  described,  the  Distoma 
lanceatum  (lancet  fluke) ,  and  the  Distoma  sinensis  are  the  most  fre- 
quent, occurring  in  the  liver,  the  last  being  most  important. 

The  Fasciola  hepatica,  common  to  ruminants,  and  the  Opisthor- 
chis  (Distoma)  felineus,  occurring  in  Prussia  and  Siberia,  and  found 
in  cats  in  Nebraska,  are  the  other  varieties. 

In  general,  we  may  say  the  liver  fluke  is  of  leaf  shape.  It  ma}' 
vary  in  length  from  10  to  20  mm.  by  2  to  5  to  10  mm.  broad.  The 
cephaUc  end  projects  like  a  beak  and  has  a  small  cup-like  sucker,  in 
which  lies  the  mouth.    Behind  this,  on  the  ventral  surface,  is  a  second 


INTESTlNAIv   PARASITES 


693 


cup,  and  between  the  two  is  a  special  orifice.    The  uterus  appears  as  a 
convoluted  bag  behind  the  posterior  sucker.     On  each  side  of  the 
body  are  the  ovisacs  and  the  branched 
testicular  canals  (Fig.  249). 

The  eggs  are  oval,  25  to  30/^-  long 
by  15  to  17/-^  broad,  of  brown  color, 
with  a  sharply  defined  operculum  (lid) 
(Fig.  250). 

The  Distoma  lanceolatum,  another 
variety  of  liver  fluke,  has  a  lancet 
shape  and  the  head  is  not  especially 
marked  off  from  the  body  (Fig.  251). 
The  eggs  are  rather  small,  0.04  mm. 
long  (Fig.  252). 

Young  children  suffer  more  fre- 
quently from  liver  fluke;  sometimes 
whole  families  or  villages  are  attacked. 

There  is  an  irregular  diarrhea ;  there 
may  or  may  not  be  blood.  The  liver  en- 
larges. There  is  often  pain  and  an  in- 
termittent jaundice,  but  not  much  fever 


of  Distoma 
hepaticuni  and  Distoma  lanceo- 
latum, moderately  magnified 
(Heller). 


Anasarca  and  ascites  come 


on  later.    The  ova  of  the  parasite  are  found  in  the  stool. 


Fig.  251. — Distoma  lanceolatum  with  its  inner  organs;    X  10  (Leuckarfj. 

Intestinal  Distomiasis. — In  India  the  Distoma  fasciolopsis  has 
been  found  in  a  number  of  cases  in  the  small  intestine,  with  diarrheal 
symptoms. 


Fig.  252. — Egg  of  Distoma  lanceolatum  shortly  after  the  formation  of  a  shell; 

X  400  (Leuckart). 

Hemic  Distomiasis;    Distoma    Hcematobium;  Bilharziasis;  Schis- 
tosoma  HcBmatobium;    Bilharzia    Hcvmatobia. — Endemic    hematuria, 


694 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


particularly  in  Egypt,  had  been  known  for  many  years,  when  in  1851 
Bilharz  discovered  the  parasite  of  the  disease.  The  blood  fluke  pre- 
vails in  South  Africa  (the  Transvaal) ;  in  North  Africa,  especially  in 
Egypt;  in  Arabia,  Persia,  and  the  west  coast  of  India.  It  is  preva- 
lent in  Japan.  It  has  been  observed  in  Porto  Rico  and  in  the  Philip- 
pines. The  disease  is  rare  in  the  United  States,  only  7  cases  having 
been  reported.  In  addition,  7  cases  occurred  among  the  Boers,  who 
were  on  exhibition  in  this  country  after  the  African  War. 

The  first  case  of  rectal  infection  reported  in  the  United  States 
was  in  a  German,  who  evidently  contracted  the  disease  in  Brazil  and 
who  was  treated  at  the  German  Hospital.     He  suffered  from  mixed 
infection — Strongyloides    intestinaHs,    Trichocephalus,   and    Schis- 
tosoma  hffimatobium,   reported  by 
I/.  Blumgart,^  of  New  York. 

The  Schistosoma  has  separate 
sexes  and  carries  the  female  in  a 
gynecophorous  canal.  The  male  is 
from  12  to  14  mm.  long.  Its  body 
has  ciliated  warts  on  the  integument, 
but  otherwise  is  smooth,  and  in  the 
posterior  portion  is  rolled  up  into  a 
tube,  which  serves  for  the  reception 
of  the  female  (Fig.  253). 

There  is  a  sucker  at  the  anterior 
end  and  a  second  one  posterior  to 


Fig.  253. — Male   and   female   of 
Bilharzia  hsematobia  (Loos). 


Fig.  254. — Eggs  of  Distomum  haema- 
tobium (Bilharzia  hsematobia),  length, 
0.12  mm.;  breadth,  0.05mm.:  o,  Egg  with 
lateral  spine;  b,  egg  with  terminal  spine; 
X  150  (after  Bilharz). 


it  on  the  ventral  surface.  The  female  is  from  16  to  18  mm.  long  and 
nearly  cyHndric.  The  eggs  have  a  terminal  or  lateral  spine  (Fig.  254). 
The  trematode  is  most  abundant  in  the  blood  of  the  portal  system, 
while  the  ova  lodge  in  the  capillaries,  especially  of  the  bladder,  urin- 
ary organs,  rectum,  and  lungs.  In  the  stools  of  the  case  reported, 
the  spine  was  placed  laterally  on  the  ova. 

Infection  is  now  considered  to  take  place  in  two  ways — either  by 
the  gastro-intestinal  tract,  through  infected  food  or  water,  or  through 
the  skin  by  bathing  in  infected  streams. 

1  Medical  Record,  April  6,  1907. 


INTESTINAL  PARASITES  695 

The  parasite  reaches  the  portal  system,  where  it  develops.  The 
males,  bearing  the  females,  creep  to  various  parts,  particularly  the 
bladder  and  rectum.  The  eggs  are  laid  in  the  tissues,  but  wander  like 
other  sharp  foreign  bodies,  and  escape  with  the  urine  and  feces. 
The  eggs  in  the  tissues  cause  irritation,  fibroid  changes,  and  papillomata 
in  the  bladder  and  rectum.  Hematuria  and  bladder  irritation,  chronic 
cystitis,  tenesmus,  mucus  and  blood  in  the  stools,  ulcerative  proctitis, 
calculi  in  the  kidney  and  bladder,  peri-urethral  abscess  and  perineal 
fistula,  vaginitis,  inflammation  of  the  ureters  and  seminal  vesicles, 
may  all  occur.     Bilharzial  colitis  has  been  reported. 

Anemia  is  present  and  eosinophilia  is  quite  marked. 

In  1904  there  was  described  a  new  blood  fluke.  Schistosoma  Cattoi, 
or  Japanicum,  found  in  Japan.  It  lives  chiefly  in  the  vessels  of  the 
ahmentary  canal  and  ulcerative  lesions  are  found  therein.  The  ova 
appear  in  the  feces.  Katsurada  has  studied  numerous  cases.  This 
condition  is  known  in  Japan  as  the  "Katayama  disease,"  from  the 
name  of  a  town  in  which  it  is  quite  prevalent. 

Catto  described  certain  bodies  he  found  in  a  Chinaman  in  1904, 
and  the  new  fluke  is  sometimes  called  by  his  name. 

Paul  G.  Woolley^  has  reported  a  case  occurring  in  the  Philippines, 
and  has  given  an  excellent  description  of  the  disease. 

The  worms  are  characterized  by  the  absence  of  ciliated  warts  on 
the  integument,  which  are  a  feature  of  the  Schistosoma  hcBmatohium. 
The  worm  averages  10.43  mm.-  long.  The  eggs  are  smaller,  brown  in 
color,  have  blunter  ends,  and  no  spine. 

Katsurada  gives  the  most  definite  reports  of  the  disease  "Kata- 
yama," according  to  Woolley: 

"  Defective  physical  development  is  the  rule  in  the  affected  children. 
Diarrhea  is  usually  the  first  symptom  to  be  noted,  while  anemia  and 
ascites  generally  follow  later;  the  most  striking  feature  is  the  shape 
assumed  by  the  trunk.  The  hypogastric  region  seems  to  shrink,  while 
the  epigastric  enlarges,  a  transverse  furrow  forming  directly  above  the 
umbilicus,  so  that  the  general  appearance  of  the  abdominal  region  is 
that  of  an  inverted  gourd.  Dilatation  of  the  epigastric  region  and  of 
the  lower  part  of  the  thorax  were  noted  even  in  patients  whose  liver 
and  spleen  were  not  much  enlarged.  The  commonest  symptoms  are 
an  initial  increase  in  the  size  of  the  liver,  followed  by  a  decrease,  a 
secondary  enlargement  of  the  spleen,  a  mucosanguineous  diarrhea, 
severe  attacks  of  ascites,  and  progressive  anemia."  Katsurada  found 
the  ova  of  the  parasite  under  discussion,  and  also  those  of  Tricho- 
cephalus  dispar,  Uncinaria,  and  Ascaris  lumbricoides  in  the  stools  of 
his  patients. 

The  rectum  and  appendix  were  the  parts  chiefly  affected,  but  the 
ova  were  found  in  the  subperitoneal  layer,  the  submucosa,and  mucosa, 
especially  in  necrotic  areas,  from  the  cecum  to  the  anus.  Adult 
trematodes  were  found  in  the  blood-vessels. 

1  Philippine  Journal  of  Science,  Jan.,  1906,  vol.  i,  No.  i. 


696 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


In  Woolley's  case  there  were  also  amebge  and  the  ova  of  the  unci- 
naria ;  but  in  the  fibroid  tissue  of  the  submucosa  of  the  large  intestine 
there  were  many  ova  of  the  Schistosoma  Japanicum  surrounded  by 
round-cell  infiltration  (Fig.  255).  A  type  of  cirrhosis  was  pro- 
duced in  the  liver.  Splenomegaly,  ascites,  dysentery  (specific),  and 
possibly  Jacksonian  epilepsy  may  be  produced  by  these  trematodes, 
according  to  Woolley. 

The  disease  is  probably  water-borne,  originating  in  rice-fields  or 
irrigated  gardens,  from  human  fertilizer.  Infection  may  occur  through 
the  skin  or  by  the  gastro-intestinal  canal. 

Treatment. — The  extract  of  the  male  fern  is  recommended  for  dis- 
tomiasis  and  the  treatment  as  of  tapeworm.  Nothing  has  been  found 
for  the  treatment  of  the  parasite  in  the  blood.    The  author  would 


Fig.  255. — Schistosoma  Japanicum.  Ova  in  mucosa  and  submucosa  of  large 
intestine.  Shows  atrophic  and  infiltrated  condition  of  mucosa.  Hematoxylin 
(Woolley). 


suggest  the  trial  of  Urotropin,  gr.  10  (0.6),  and  sodium  benzoate,  gr.  10 
(0.6),  three  or  four  times  a  day.  The  latter  lessens  the  irritation  of 
the  urotropin,  as  demonstrated  by  William  H.  Thomson. 

The  inflammation  of  the  bladder,  colon,  and  rectum  should  be 
treated  as  indicated  by  irrigation,  etc.  Solutions,  as  described  under 
Proctitis  and  Colitis,  can  be  employed  for  the. latter  complications. 

Neniatodes  (Round  Worms). — Round  worms  have  a  slender, 
cylindric,  at  times  a  filiform  body,  with  neither  segments  nor  append- 
ages. The  integument  is  thick  and  elastic.  The  mouth  is  at  one 
extremity  and  furnished  with  either  soft  or  horn-like  lips.  The  ali- 
mentary canal  extends  through  the  entire  body  and  terminates  in  an 
opening  on  the  ventral  side  near  the  posterior  extremity.  The  sexual 
organs  and  their  orifices  are  on  the  ventral  surface.     The  female 


INTESTINAL  PARASITES 


697 


aperture  is  at  the  middle  of  the  body,  while  in  the  male  the  sexual 
orifice  is  near  the  anus.  The  males  are  usually  smaller  than  the 
females. 

Ascaris  Lumbricoides  (Round  or  Spool  Worm). — This  is  one  of 
the  common  parasites  observed  in  man.  It  is  cylindric  in  shape, 
pointed  at  both  ends,  and  of  a  yellowish-brown  or  slightly  reddish 
color.  It  varies  from  4  to  12  inches  (10-30  cm.)  in  length,  the 
female  being  as  large  as  12  inches  {30  cm.),  while  the  male  is  only 
one-half  or  two-thirds  the  length,  8  inches  (20  cm.),  and  frequently 
much  smaller. 

The  posterior  extremity  of  the  male  is  bent  in  the  shape  of  a  hook 
and  furnished  with  two  spicules  or  chitinous  processes  (Fig.  256).  The 
mouth  has  three  muscular  lips  provided  with  very  fine  teeth. 


Fig.  257. — Eggs  of  Ascaris  lum- 
bricoides, double  shell;  albuminous 
envelope,  magnified  (Hosier  and 
Peiper). 


Fig.  256. — Ascaris  lumbricoides:  a,  Body; 
b,  head;  c,  eggs  (after  v.  Jaksch). 


Fig.   258. — Unfertilized  egg  of   As- 
caris lumbricoides;  X500  (Logan). 


The  worm  is  transversely  striated  and  has  four  longitudinal  bands. 

The  sexual  opening  of  the  female  is  anterior  to  the  middle  of  the 
body.  The  eggs  when  ripe  have  a  double  shell,  and  around  this  is  an 
albuminous  envelope,  irregular  in  shape,  studded  with  excrescences 
(Fig.  257).  The  long  diameter  of  the  ovum  is  about  0.075  "^"i-  ^"d 
0.058  mm.  in  width.  Atypic  (unfertilized)  eggs  have  been  described 
by  O.  T.  Logan^  of  China.  When  taken  from  the  uterus  it  has  not 
the  typic  thick  shell,  but  is  granular,  elliptic,  and  enclosed  in  a  deli- 
cate membrane  (F'ig.  258). 

1  New  York  Medical  Journal,  Dec.  21,  1907. 


698  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

In  the  feces,  the  yelk  is  not  finely  granular,  but  coarsely  globular; 
the  albuminous  coat  is  less  voluminous  and  projects  from  the  shell 
like  blunt  saw  teeth.  The  unfertilized  egg^  is  longer  and  narrower 
than  the  fertilized  egg  and  markedly  elliptic,  with  a  tendency  to  flat- 
ten at  one  or  both  ends.    It  is  occasionally  oval,  but  never  round. 

An  irritating,  odoriferous  substance  is  formed  by  the  round  worm. 
Huber^  states  that  it  may  occasion  urticaria  in  those  predisposed  to 
this  symptom.  Peiper  suggests  that  the  nervous  symptoms,  some- 
times resembling  meningitis,  may  be  due  to  this  poison ;  and  Chauf- 
fard  and  Marie  report  fever,  intestinal  symptoms,  diarrhea  of  inter- 
mittent character  and  foul  breath,  so-called  typholumbricosis,  in 
connection  with  these  worms.  The  fever  may  continue  for  a  month 
or  more. 

The  parasitic  life  history  is  direct,  by  ingestion  of  the  ova,  with  no 
intermediate  host.  The  parasite  occupies  the  upper  part  of  the  small 
intestine.  Usually  not  more  than  one  or  two  are  present,  but  they 
may  occur  in  enormous  numbers. 

Infection  usually  takes  place  by  eggs  in  the  soil  near  dwelUngs,  in 
the  drinking-water,  and  especially  in  raw  foods,  such  as  salads  and 
fruits.  These  worms  occur  more  frequently  in  children  from  three  to 
twelve  years  of  age  and  in  the  poorer  class.  They  are  not  so  frequent 
in  adults.    Females  seem  more  frequently  infected. 

Migration. — The  worms  may  crawl  into  the  stomach,  whence 
they  may  be  ejected  by  vomiting;  or  they  may  pass  through  the 
esophagus  and  enter  the  phar5^nx,  whence  they  may  be  withdrawn. 
The  \'\'orm  has  entered  the  larynx  and  has  produced  fatal  asphyxia, 
or  into  the  trachea  and  lungs  and  caused  gangrene.  They  have  passed 
through  the  Eustachian  tube  and  appeared  at  the  external  meatus. 
They  have  been  found  in  the  bile-ducts,  the  gall-bladder,  and  even 
in  the  Uver,  where  they  produced  fatal  abscess.  They  have  entered 
hernial  sacs,  perforated  intestinal  ulcer,  and  some  claim  even  the 
healthy  bowel  wall  has  been  perforated  by  them.  Appendicitis  has 
been  attributed  to  the  ascaris ;  and  obstruction  of  the  bowel  is  said  to 
have  been  produced  by  a  large  mass  of  ascarides. 

Symptoms. — They  may  produce  no  symptoms.  In  children,  irri- 
tability, restlessness,  picking  at  the  nose,  grinding  the  teeth,  twitch- 
ings  or  convulsions,  have  been  attributed  to  them.  Anorexia,  nausea, 
irregular  bowel  action,  meteorism,  irregular  pulse,  and  black  rings 
around  the  eyes  may  also  occur.  In  rare  instances  progressive  anemia 
has  been  observed.  Itching  of  the  nose  may  be  present.  The  worms 
probably  produce  local  hyperemia  of  the  intestinal  walls. 

Diagnosis. — ^This  is  made  by  the  detection  of  the  worm  or  of  its 
ova  in  the  stools. 

Treatment. — The  stools  should  be  disinfected  by  carbolic  (5  per 

1  New  York  Medical  Journal,  Aug.  19,  1905  (Wellman);  Reference  Hand- 
book Medical  Sciences,  p.  502. 

2  Twentieth  Century  Practice  of  Medicine,  vol.  viii,  p.  583. 


INTESTINAL   PAR.\SITES  699 

cent.)  or  bichlorid  (i :  1000)  solution  to  destroy  the  ova.  The  hands 
should  be  disinfected  and  all  food  protected  against  infection. 

It  is  preferable  to  administer  a  simple  saline  for  a  couple  of  days 
and  keep  the  patient  on  a  light  diet  before  administering  the  anthel- 
mintic. 

Santonin  is  the  best  remedy.  It  can  be  given  mixed  with  sugar 
in  doses  of  gr.  |  to  |  (0.022-0.032)  for  a  child,  and  gr.  2  to  3  (0.13- 
0.194)  for  an  adult,  followed  by  calomel  or  a  saline  purge. 

It  can  be  administered  in  divided  doses;  thus,  santonin,  gr.  i 
(0.06),  three  or  four  times  a  day,  followed  by  a  purge;  or  santonin, 
gr.  3J  (0.2),  with  castor  oil,  oij  (60.0) ;  give  i  teaspoonful  for  a  small 
child;  I  dessertspoonful  for  a  larger  child;  i  tablespoonful  for  an 
adult,  two  or  three  times  daily  (Einhom). 

Santonin,  gr.  ^  (0.022) ;  hydrargyrum  choridum  mite,  gr.  i  to  2 
(0.065-0.13).  Give  one  powder  t.  i.  d.  Yellow  vision  (xanthopsia) 
occasionally  follows  the  use  of  santonin. 

Chenopodium  (powdered  seeds),  in  doses  of  gr.  xv  to  xxx  (i.o- 
2.0),  or  oleum  chenopodii,  IfVLij  to  x  (0.118-0.592),  followed  by  a 
cathartic,  have  been  employed. 

Thymol,  gr.  viiss  to  xxx  (0.5-2.0),  given  in  capsules  in  divided 
doses  and  followed  by  a  saline  cathartic,  has  been  recommended. 


Fig.  259. — Oxyuris  vermicularis:  Female,  enlarged  (Hosier  and  Peiper). 

Enteroclysis  with  water,  to  which  a  few  drops  of  benzine  are  added, 
has  been  suggested;  but  I  scarcely  see  the  benefit,  as  the  habitat  of 
the  worms  is  in  the  small  intestine. 

Ascaris  Mystax. — ^This  is  a  round  worm  resembling  the  ascaris 
lumbricoides,  but  smaller  and  thinner.  It  is  found  chiefly  in  cats  and 
rarely  in  man.     No  special  symptoms  result. 

Oxyuris  Vermicularis  (Thread-worm;  Pin- worm;  Seat- worm  ; 
Awl-tail ;  Maggot-worm). — This  parasite  occupies  the  rectum  and 
colon.    It  is  white  and  filiform. 

The  male  measures  about  4  mm.  (|  inch)  in  length  and  the  female 
about  10  mm.  (f  inch)  (Fig.  259).  It  has  three  small  nob-like  lips.  The 
female  has  two  uteri,  passing  backward  and  forward  from  the  end  of 
the  vagina.  The  opening  of  the  latter  is  situated  above  the  middle 
of  the  body.  The  eggs  are  0.05  mm.  long  and  about  0.02  mm.  wide, 
with  granular  contents  and  white  shell  (Fig.  260). 

Huber  and  others  claim  that  they  are  generally  deposited  outside 
the  body,  so  that  feces  rarely  contain  them;  while  Osier  holds  that 
they  are  usually  found  in  the  feces  in  large  numbers.  These  worms 
occur  at  any  age,  though  most  commonly  in  children.  The  worms  are 
found  in  the  feces,  at  the  anus,  or  in  the  vagina. 


700 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


Infection  takes  place  through  drinking-water  or  through  salads, 
radishes,  fruits,  etc.,  the  ova  being  dried  upon  them,  or  through  the 
unwashed  hands  of  the  host. 

The  eggs  of  the  oxyuris  reach  the  stomach,  when  the  shell  opens 
and  the  embryo  migrates  into  the  small  intestine.  After  fructification 
the  females  pass  along  the  canal  to  the  cecum,  where  they  remain 


I,  Female;  2,  males;  3,  ovum,  magnified. 
Fig.  260. — Oxyuris  vermicularis,  natural  size  (Vierordt). 

until  the  eggs  are  ripe,  and  then  pass  on  downward,  chiefly  to  the  sig- 
moid and  rectum.  The  oxyuris  may  traverse  the  intestinal  wall  and 
have  been  found  in  the  peritoneal  cavity,  where  they  may  form  ver- 
minous tubercles  in  Douglas'  fossa  or  perirectal  abscesses. 

Symptoms. — ^The   oxyuris   produce   great   irritation   and   itching 
around  the  anus,   particularly  at  night.     The  pruritis  ani  is  pro- 


Fig.  261. — Segmentation  and   development  of  embryo  of  Oxyuris  vermicularis 

(Heller). 


nounced.  The  patient  becomes  nervous  and  irritable,  sleep  is  dis- 
turbed. There  mav  be  anorexia,  nausea,  dizziness,  palpitation, 
pollutions  in  the  male,  occasionally  diarrhea,  and  at  times  anemia. 
Sometimes  the  parasites  enter  the  vagina  and  cause  irritation  or 
n^^mphomania. 

Diagnosis. — The  worms  are  easily  detected  in  the  feces  and  are 


INTESTINAL  PARASITES  7OI 

readily  diagnosed  by  their  appearance  and  location  through  inspec- 
tion of  the  anus. 

Treatment. — Cleanliness  of  the  hands  of  the  infected  person  and 
disinfection  of  stool,  clothes,  and  bedclothes  are  important.  Sleeping 
with  an  infected  case  should  be  forbidden. 

Raw  fruits  should  be  cleaned  and  peeled,  salads,  etc.,  thoroughly 
washed.    One  should  not  eat  out  of  the  same  vessels  as  the  patient. 

Santonin,  administered  by  the  same  method  as  for  ascaris,  is  an 
excellent  remedy.  Local  treatment  by  enemata  of  water,  i  quart 
(liter)  containing  TTLv  to  x  (0.296-0.592)  of  benzine,  or  vinegar 
oiss  to  ij  (45.0-60.0),  or  thymol  (i :  2500)  by  enema,  or  fiuidextract  of 
quassia,  TTlx  to  xxx  (0.292-1.704)  to  the  quart;  or  soak  a  quassia  cup 
in  water  for  half  an  hour  and  inject  quassia  water,  Oj  (500  cc). 

An  enema  of  spirits  (oil)  of  turpentine,  5j  (4.0)  to  Oj  (500  cc.) 
of  water,  is  of  value. 

These  injections  should  be  given  with  hips  elevated  and  retained 
for  a  short  period.  Cold  injections  of  strong  salt  water  are  of  ser- 
vice in  children.  Carbolic  acid  I  believe  unsafe.  Injections  of  lime- 
water  are  of  use. 

Black  wash — calomel,  oj  (4-0);  lime-water,  Oj  (500  cc.) — locally, 

externally;  lead-and-opium  lotion,  unguentum   belladonna,  vaselin, 

or 

I^.     Unguent,  belladonnse oij  (8.0) 

Tr.  aconite  radix 3ss  (2.0) 

Zinc  oxid gr.  xv  (i  .0) 

Unguent,  aq.  rosse q.  s.  o j  (30.0). — M. 

Sig. — Ft.  ung.     External  use  to  anus. 

Cocain,  gr.  ss  (0.32),  can  be  added  to  this.  These  preparations 
lessen  itching. 

The  saline  enemata,  given  frequently,  are  of  use. 

Ankylostoma  (Anchylostoma)  Duodenale ;  Uncinariasis ; 
Hookworm  Disease  ;  Miner's  Anemia  ;  Egyptian  Chlorosis  ; 
Dochmius  Duodenalis  or  Strongylus  Duodenalis.— In  1843 
Dubini  first  described  this  parasite  in  man.  Griesinger,  in  1854, 
demonstrated  it  as  the  cause  of  Egyptian  chlorosis.  Subsequently  it 
was  described  in  the  tunnel  workers  of  St.  Gothard,  and  it  is  now 
recognized  as  an  important  cause  of  tropical  anemia  and  of  the  anemia 
of  miners,  brick  workers,  and  tunnel  workers. 

Incidence. — This  parasite  is  widely  spread  in  tropical  and  sub- 
tropical countries,  and  is  one  of  the  most  fatal  of  parasitic  diseases. 
In  Porto  Rico,  in  1903,  5736  deaths  out  of  a  total  of  23,433  were  from 
anemia  due  to  uncinariasis,  as  shown  by  the  Anemia  Commission  in 
the  report  issued  by  Ashford  King  and  Igaravidez.  Stiles  has  dem- 
onstrated that  the  disease  is  endemic  in  many  places,  and  is  the  cause 
of  the  common  anemia  in  the  Southern  States. 

Bass^  has  reported  a  large  number  of  cases  in  the  country  popu- 

1  Journal  American  Medical  Association,  July  21,  1906. 


702 


DISEASES   OF  THE   STOMACH  AND  INTESTINES 


lation  of  Mississippi.  Uncinariasis  has  been  found  among  the  miners 
in  Pennsylvania.  It  is  not  uncommon  in  the  PhiHppines.  The  disease 
is  prevalent  among  the  miners  of  Germany  and  Austro-Hungary  and 


Fig.  262. — Ankylostomum  duodenale:  o,  Male  (natural  size);  b,  female  (natural 
size) ;  c,  male  (enlarged) ;  d,  female  (enlarged) ;  e,  head;  /,  eggs  (after  v.  Jaksch). 

also  in  Westphalia.  The  anemia  of  the  Cornish  miners  has  been 
shown  to  be  due  to  hookworm.  In  Egypt  the  disease  is  very 
prevalent. 


Fig.  263. — Posterior  extremity  of  female  Uncinaria  Americana,  viewed  ven- 
trolaterally,  showing  anal  opening  expanded:  o,  a,  Anal  papillae,  showing  small 
chitinous  tips  (A.  J.  Smith). 

Parasite. — The  worm  is  a  strongyle,  closely  allied  to  the  scleros- 
toma,  which  causes  verminous  aneurysms  and  colic  in  the  horse,  and 
to  the  gapeworm  of  fowls.  There  are  two  forms — the  Anchjdostoma 
duodenale  and  the  Uncinaria  Americana — described  by  Stiles.  They 
have  the  same  general  characteristics,  there  being  certain  differences 
in  the  arrangement  of  the  teeth,  etc. 


INTESTINAL   PARASITES 


703 


The  worm  is  cylindric  in  shape,  about  0.5  to  i  mm.  thick.  The 
males  are  from  7  to  11  mm.  in  length,  the  females  10  to  18  mm.  The 
American  worm  is  the  longer.  The  worm  is  yellowish  or  grayish 
white  in  color,  with  translucent  edges.  The  head  is  curved  toward  the 
dorsal  surface  and  the  mouth  is  provided  with  a  heavy  armature  of 
hook-like  teeth,  with  which  they  pierce  the  mucosa.  There  is  a  strong 
muscular  esophagus.  The  male  has  a  prominent  caudal  expansion  or 
bursa  (Fig.  262). 

In  the  female  the  caudal  end  is 
pointed  and  armed  with  an  awl-like 
prong  (Fig.  263).  The  eggs  are  oval, 
64  to  76/^  long  by  36/^-  wide  (Fig.  264) 
in  the  American  form.  They  are  laid 
in  segmentation.  The  development  is 
direct,  without  an  intermediate  host. 
The  European  eggs  are  smaller. 

The  embryo  lives  in  the  water  or 
moist  ground  and  passes  through  the 
rhabditiform  stage.  Larvae  may  live 
for  months  in  the  mud  and  water  of 
the  mines.  They  may  be  taken  into 
the  body  by  drinking-water,  with  the 
dirt  from  the  hands  of  the  miners  and 
tunnel  workers,  or  in  the  soil  eaten  by 
the  earth  feeders,  the  geophagi.  They 
may  be  carried  in  the  dust  and  con- 
taminate green  vegetables  and  fruit. 

Uncinarial  Dermatitis. — Ashford 
and  King^  refer  to  the  fact  that  in 
Porto  Rico  infections  through  the 
mouth  are  rare,  and  that  fully  96 
per  cent,  of  the  patients  have  suffered  from  ground-itch  ("Mazam- 
orra"),  due  to  invasion  of  the  skin^  by  these  larvae.  The  well  shod  were 
never  affected..  Various  stages  of  dermatitis  occur,  and  even  obsti- 
nate ulcers  of  the  leg,  in  the  lower  third  especially.  These  were  called 
"tropical"  or  "syphilitic"  by  the  ignorant.  Loos  demonstrated  that 
embryo  worms  enter  the  skin  and  are  carried  by  the  veins  to  the  right 
side  of  the  heart  and  lungs,  and  then  pass  up  through  the  trachea 
into  the  pharynx  and  are  swallowed.  Ashford  further  believes  that 
skin  infections  can  take  place  without  manifest  dermatitis  from 
experiments  on  animals.  Skin  infection  is  probably  very  frequent. 
Infection  is  mope  common  in  summer  than  winter,  in  part  prob- 
ably due  to  the  fact  that  greater  protection  is  afforded  the  lower 
limbs  during  the  cold  or  rainy  season. 

1  Uncinariasis,  Journal  American  Medical  Association,  Au.s^.  10,  1907. 

2  The  skin  eruption  known  as  "  bunches,"  occurring  in  the  Cornish  miners 
is  probably  due  to  the  entrance  of  these  worms  (Haldane). 


Fig.  264. — Four  eggs  of  the 
New  World  hook-worm  {Unci- 
naria  Americana),  in  the  one-, 
two-,  and  four-cell  stages.  The 
egg  showing  three  cells  is  a  lateral 
view  of  a  four-cell  stage.  These 
eggs  are  found  in  the  feces  of 
patients,  and  give  a  positive  di- 
agnosis of  infection.  Greatly  en- 
larged (after  Stiles). 


704  DISEASES   OF   THE    STOMACH   AND    INTESTINES 

Immunity. — Some  whites,  and  especially  the  negro  race  and  Asi- 
atics, enjoy  considerable  immunity  to  this  disease.  One  may  find  a 
large  number  of  ova  in  the  stools,  and  yet  there  may  be  few  or  no 
symptoms.  Usually  the  greater  the  infection,  the  more  acute  the 
onset  and  course  of  the  disease.  The  adult  worm  lives  in  the  small 
intestine;  more  are  found  in  the  jejunum;  many  in  the  duodenum; 
and  rarely  in  the  ileum  or  colon. 

Symptoms. — In  the  early  stage  there  may  be  gastro-intestinal 
symptoms,  such  as  pains  in  the  epigastrium  (gastralgia),  tenderness 
in  the  right  h5^pochondrium,  nausea,  occasionally  vomiting,  consti- 
pation, rarely  diarrhea.  Pain  in  the  sternum  and  chest,  slight  breath- 
lessness  on  exertion,  and  palpitation.  A  temperature  of  37.5°  to 
38.5  °  C.  (99.5  "-103.5  F.)  is  not  uncommon.  The  patient  feels  unable 
to  work;  graduallv  anemia  becomes  manifest,  the  fever  disappears, 
hemoglobin  steadily  diminishes.  Headache,  vertigo,  tinnitus  aurium, 
hemic  murmurs,  weakening  of  the  pulse,  and  dyspnea  follow.  The 
pains  in  the  sternum  become  quite  severe,  debilit}'  and  mental 
hebetude  increase;  patellar  reflexes  are  diminished  or  even  lost. 
Impotence  or  amenorrhea  may  be  present. 

In  this  advanced  condition  the  skin  is  of  a  dirty  muddy  hue,  at 
times  waxy  white.  In  the  Southern  States  it  is  known  as  the  "Flor- 
ida complexion."  The  eyes  are  dull,  heavy,  lack  lustre,  and  have  a 
blank  stare..  Children  are  interfered  with  in  their  growth  and  become 
stunted  and  ill  developed.  The  circulatory  system  becomes  more 
profoundly  affected;  the  heart,  at  first  slightly  hypertrophied,  now 
becomes  dilated  and  broken  compensation  ensues.  There  are  edema 
of  the  feet  and  legs,  pufhness  of  the  face  and  a  general  anasarca,  with 
pericardial,  pleural,  and  peritoneal  effusions.  The  patient  is  bed- 
ridden and  gradually  passes  away  in  a  semisomnolent  condition. 
Acute  cardiac  dilatation,  cerebral  effusion,  or  violent  diarrhea  may  be 
terminal  events. 

Osier  holds  that  the  liver  and  spleen  become  enlarged,  but  this 
does  not  correspond  to  the  findings  of  Ashford  and  King.  The  hemo- 
globin may  fall  below  30  per  cent,  and  sometimes  even  to  8  per 
cent.,  and  some  of  these  latter  have  recovered  under  appropriate 
treatment. 

Morbid  Anatomy. — Autopsies  (Ashford  and  King). — Muscles  are 
often  brownish  gray,  friable,  and  atrophied.  Skin  and  subcutaneous 
tissue  pale  and  sodden  with  fluid.  Serous  effusion  generally  present 
in  the  pleurae  and  pericardium,  sometimes  in  the  cerebral  ventricles. 
Ascites  marked. 

Lungs. — Edema  and  passive  congestion. 

Liver. — Never  normal;  once  was  increased  in  size;  never  dimin- 
ished; fatty  degeneration  often  present;  connective-tissue  increase  is 
not  a  feature. 

Kidneys. — Chronic  parenchymatous  or  chronic  diffuse  nephritis. 
As  a  rule,  there  was  little  connective-tissue  increase. 


INTESTINAL  PARASITES  705 

Stomach. — Uncinariae  are  occasionally  found  in  the  stomach,  even 
adherent  to  its  walls.    Chronic  gastritis  is  common. 

Intestines. — ^The  jejunum  contained  most  of  the  uncinariae,  some 
unattached  and  others  attached  to  the  mucosa.  The  balance  were 
mostly  found  in  the  first  part  of  the  duodenum,  a  few  in  the  ileum, 
and  none  in  the  colon. 

The  intestinal  lesion  is  confined  to  the  mucosa,  there  being  a  tiny 
superficial  erosion  about  0.5  mm.  (3^0  inch)  in  diameter,  and  not  a 
deep  ulcer.  They  are  usually  not  red  and  are  difficult  to  find,  except 
with  a  hand  lens.  The  duodenum  and  especially  the  jejunum  are 
the  seat  of  a  chronic  intestinal  catarrh. 

The  dejecta  are  often  of  brownish  color.  Microscopically,  eggs  of 
the  parasites  and  at  times  Charcot- Leyden  's  crystals  are  found  in  the 
stools. 

Spleen. — This  is  frequently  found  reduced  in  size,  soft,  and  has  a 
wrinkled  capsule.    There  was  a  paucity  of  lymphoid  elements. 

Hemolymph  Glands. — In  the  region  of  the  abdominal  aorta,  espe- 
cially near  the  bifurcation,  enlarged  glands  of  dull  reddish  hue  were 
noted.  There  was  no  surrounding  trace  of  imflammation.  Micro- 
scopic examination  showed  they  were  hemolymph  glands  of  the  type 
described  as  splenolymph. 

Bone-marrow. — Changes  such  as  occur  in  pernicious  anemia ;  also 
eosinophilous  cells. 

Anemia. — Blood. — The  findings  vary  from  a  diminution  of 
hemoglobin  and  red  cells  to  those  of  pernicious  anemia.  The  hemo- 
globin is  usually  relatively  lower  in  uncinariasis;  as  low  as  15  to  20 
per  cent,  in  severe  cases  is  not  uncommon,  8  per  cent,  having  been 
registered. 

Polychromatophilia,  and  in  severe  cases  poikilocytosis,  with 
macrocytes  and  microcytes,  occur.  Normoblasts  and  megaloblasts 
were  not  uncommon,  but  the  latter  were  in  the  minority.  Ery- 
throcytes averaged  2,406,416  per  cubic  millimeter,  the  lowest  754,000; 
average  hemoglobin  slightly  over  40  per  cent. 

Osier  reports  marked  leukocytosis  in  his  cases.  Some  observers 
hold  that  leukoc}i:osis  is  generally  due  to  complications;  while  Ash- 
ford  and  King  find  no  constant  leukocytosis,  but  that  it  is  present  at 
times  in  acute  cases,  while  in  chronic  cases  there  is  apt  to  be  leuko- 
penia. There  seemed  to  be  a  tendency  of  the  leukoc}i:es  to  degen- 
erate. 

Eosinophilia  is  of  importance.  Boycott  and  Haldane  hold  it  iS 
present  in  94  per  cent,  of  cases,  and  at  times  it  is  quite  high.  Ashford 
and  King  call  especial  attention  to  the  fact  that  in  the  most  serious 
cases  it  is  liable  to  be  absent,  and  that  it  is  chiefly  of  prognostic  im- 
portance. Very  chronic  cases  of  severe  type,  poor  resisting  power, 
and  lack  of  blood  regeneration,  they  state,  rarely  show  eosinophilia, 
or  only  to  a  sHght  degree;  that  a  rise  of  eosinophilia  is  of  good 
prognostic  significance;  that  a  fall,  with  lack  of  improvement  in  the 

45 


7o6  DISEASEIS   OF   THE    STOMACH   AND   INTESTINES 

symptoms,  is  not  a  good  omen.    They  hold  that  good  resistance  to 
the  toxin  of  uncinarise  is  expressed  by  eosinophilia. 

Diagnosis. — By  the  finding  of  the  eggs  and  parasites  in  the  stool. 
It  is  well  to  examine  the  stools  after  a  dose  of  thymol,  followed  by  a 
saHne  cathartic.  Stiles  suggests  placing  a  small  bit  of  feces  on  a  white 
blotting  paper  when  a  microscopic  examination  cannot  be  made. 
In  about  an  hour  there  is  a  blood-red  or  reddish-brown  stain  suggest- 
ive of  blood.  The  worms  to  the  naked  eye  are  about  J  inch  long, 
of  the  diameter  of  a  pin,  with  one  end  sharply  recurved. 

Eosinophilia  is  suggestive.  The  microscopic  examination  of  the 
stool  will  settle  the  diagnosis. 

Prognosis. — ^This  is  good  if  the  condition  is  detected  early,  but 
is  bad  in  the  advanced  cases. 

Prophylaxis. — In  camps  or  mines,  proper  sanitary  regulations, 
such  as  the  correct  location  of  the  latrines,  etc.,  are  important.  In 
regions  where  this  infection  is  endemic,  new  miners  should  be  in- 
spected, and  infected  cases  should  be  pronounced  free  from  the  dis- 
ease before  being  allowed  to  resume  work.  The  feet  and  legs  should 
be  protected  from  the  soil  (should  not  be  bare)  and  the  hands  prop- 
erly scrubbed  before  eating.  The  stools  of  infected  patients  should 
be  disinfected  with  bichlorid  of  mercury  (i:iooo)  or  carbolic  acid 
(1:20)  solution. 

Raw  fruits  and  vegetables,  such  as  apples,  lettuce,  etc.,  should  be 
properly  cleaned,  and  should  preferably  be  avoided  if  there  are  many 
cases  of  ankylostomiasis. 

'  Treatment. — ^Filix  mas,  thymol,  and  betanaphtol  are  the  best 
drugs.  The  ethereal  extract  of  filix  mas,  same  dosage  as  for  tape- 
worms, and  then  the  solid  extract  were  tried  in  Porto  Rico,  but  they 
seemed  to  be  of  no  value.  Ashford  beheves  that  possibly  the  prepa- 
ration deteriorates  in  warm  climates. 

Thymol  proved  to  he  the  best  remedy.  The  day  previous  the  patient 
abstains  from  soHd  food  and  at  night  is  given  25.0  gm.  sodium  sul- 
phate or  any  good  saline  cathartic ;  the  next  morning,  if  free  bowel 
action,  on  an  average  about  gr.  30  (2.0)  of  thymol  should  be  given, 
and  an  equal  dose  two  hours  later,  followed  in  a  couple  of  hours  by 
another  saline  cathartic. 

This  procedure  should  be  kept  up  once  a  week,  until  no  ova  are 
found.  Smaller,  occasionally  even  larger,  or  more  frequent  doses  may 
be  required.  It  is  generally  advised  that  oily  cathartics,  such  as  castor 
oil  and  also  alcohol,  should  not  be  taken  directly  after  the  thymol. 
Dizziness  or  slight  collapse  may  follow  the  use  of  thymol.  Ashford 
mentions  cases  who  have  taken  alcohol  for  these  conditions  with  no 
deleterious  effect. 

Betanaphtol,  gr.  xv  (i.o),  and  two  hours  later  the  same  dosage, 
administered  like  thymol,  have  been  employed.  It  is  somewhat 
irritating  to  the  kidneys;  is  an  excellent  anthelmintic,  but  not  quite 
as  safe  as  thymol  nor  as  efficacious. 


INTESTINAIv   PARASITES 


707 


Ashford  and  King  hold  that  hemoglobin  increased  more  rapidly 
under  the  use  of  iron,  but  that  the  return  to  normal  came  about  as 
surely  without  it,  after  the  use  of  thymol.  They  used  Blaud  's  pills  in 
obstinate  cases.     Iron  and  arsenic  I  believe  valuable  accessories. 

I^.     Blaud's  pill  (iron)  (made  fresh) gr.  v  (0.3) 

Sod.  arsen gi".  -^V  (0.0013). — M. 

One  pill. 
Sig.— One  t.  i.  d. 


Peptomangan  (Gude),  oj  to  iij  (4.0-12.0),  or  Blaud's  iron  pill, 
gr.  V  to  X  (0.3-0.6),  or  iron  tropon  can  be  used,  combined  with  Fow- 
ler's   solution    of   arsenic,    TTLv    (0.274) 
t.  i.  d.;  or  atoxyl,  gr.  ^  (0.02),  by  hypo- 
dermic every  other  day. 

A  subsequent  high  enema  of  thymol, 
I  quart  (liter),  1 12500,  might  be  of  value 
in  aiding  their  destruction  after  the 
worms  have  passed  into  the  large  intes- 
tine. 

Strongyloides  Intestinalis. — Under 
this  name  we  now  include  the  small 
nematode  worms  found  in  the  feces  and 
formerly  described  as  Anguillata  sterco- 
ralis,  Anguillata  intestinalis,  and  Rhab- 
donema  intestinale.  The  parasite  occurs 
abundantly  in  the  stools  of  the  endemic 
diarrhea  of  hot  countries,  and  has  been 
described  by  the  French  in  the  diarrhea 
of  Cochin-China.  It  has  been  found  in 
Manila  by  Strong. 

W.  S.  Thayer  reported  3  cases  from 
Osier's  clinic.    It  has  occurred  in  Italy. 

Blumgart^  reports  their  larvae  in  a 
case  and  refers  to  reports  of  5  additional 
cases,  and  to  the  fact  that  Southern 
physicians  refer  to  other  cases,  so  that  the  disease  is  probably  more 
widespread  than  is  supposed.  The  worms  are  said  to  occupy  all 
parts  of  the  intestines,  and  have  even  been  found  in  the  biliary  and 
pancreatic  ducts. 

The  female  is  from  i  to  2.20  mm.  long  and  0.04  to  0.03  mm.  wide; 
the  male  is  about  a  fifth  smaller  (Fig.  265).  The  mouth  has  three  dis- 
tinct lips,  continuous  with  a  triangular  esophagus,  which  after  narrow- 
ing dilates  again  into  a  second  ovoid  enlargement,  which  is  followed 
by  intestines.    The  intestinal  tract  is  bordered  by  fine  granulations. 

Eggs  are  elliptic,  with  a  thin,  clear  yellow  shell,  with  granular 
contents  about  0.00675  by  0.0375  mm.     They  hatch  quickly,  so  are 


Fig.  265.  —  Strongyloides 
intestinalis  and  stercoralis:  i, 
Larva  (Anguillula  intesti- 
nalis) ;  2,  male  Anguillula  ster- 
coralis; 3,  female  Anguillula 
stercoralis  (after  Perroncito), 


1  Medical  Record,  Ajiril  6,  1907, 


7o8 


DISEASES    OF   THE    STOMACH    AND    INTESTINES 


rare  in  the  stools.  They  occur  chiefly  in  the  duodenum  and  jejunum, 
but  have  been  found  in  the  stomach  and  other  parts  of  the  intestines. 

Symptoms. — They  are  usually  more  of  chronic  diarrhea  than -of 
dysentery.  There  are  at  first  mild  dyspeptic  symptoms,  eructations, 
anorexia,  and  a  diarrhea  of  moderate  intensity,  with  soft  and  pasty 
stools,  three  or  four  a  day,  often  in  the  early  morning  hours.  The 
attacks  are  sometimes  dysenteric,  with  mucus  and  blood;  in  other 
cases  they  are  more  choleraic,  the  dejecta  consisting  of  liquid  yellow 
material ;  while  vomiting,  cyanosis,  and  collapse  may  occur. 

Emaciation  and  prostration  may  be  present.  Anemia  is,  as  a 
rule,  not  very  severe.  Intercurrent  dysentery  is  not  uncommon,  also 
headache,  vertigo,  tinnitus  aurium,  and  prostration. 

Treatment. — Rest  and  liquid  diet.  Male  fern,  ethereal  extract, 
12  to  30  gm.,  divided  in  three  doses  during  the  morning  and  repeated 
daily,  have  been  used  by  the  Italians. 

Thymol  has  been  quite  successful. 

Large  quantities  of  olive  oil  have  seemed  to  give  good  results  in 
some  cases. 

Trichocephalus  Dispar  (Whip- worm). — This  parasite  is  found 
in  the  cecum  and  large  intestine  of  man.    It  measures  from  4  to  5  cm. 


Fig.  266. — Trichocephalus  dispar:  o,  Fe- 
male; b,  male  (natural  size)  (Heller). 


Fig.  267. — Egg  of  Trichocepha- 
lus dispar,  moderately  enlarged 
(Heller). 


long,  the  male  being  smaller  than  the  female.  It  is  readily  recognized 
by  the  peculiar  differences  between  the  anterior  and  posterior  por- 
tions. The  anterior  forms  three-fifths  of  the  body,  is  thin  and  hair- 
like; the  tail  end  of  the  female  is  more  conic  and  thicker,  terminating 
in  a  blunt  extremity;  while  that  of  the  male  is  rolled  like  a  spring 
(Fig.  266). 

The  ovum  is  lemon  shaped,  dark  brown,  0.05  mm.  in  length,  and 
provided  with  button-like  projections  (Fig.  267). 

The  number  of  worms  is  variable,  as  many  as  a  thousand  having 
been  counted ;  often  only  ten  to  twenty  are  found.  In  parts  of  Europe 
they  are  very  common,  but  not  so  in  the  United  States.  Profound 
anemia  with  diarrhea  have  occurred  from  them.  Many  worms  may 
be  present  without  producing  symptoms ;  occasionally  diarrhea  and 
nervous  symptoms  occur. 

Diagnosis. — This  can  be  made  from  the  peculiar  ova.  Living 
worms  are  rare  in  the  stool. 


INTESTINAI.  PARASITES 


709 


Treatment. — Thymol,  as  previously  described.  Extract  of  male 
fern  may  be  employed.  High  enemata  of  warm  water,  i  quart  (liter), 
containing  5  to  10  drops  of  benzin,  may  be  of  service. 

Trichina  Spiralis  (Trichiniasis). — The  trichina  in  its  adult 
condition  lives  in  the  small  intestine.  The  embryos  pass  from  the 
intestines  and  reach  the  voluntary  muscles,  where  they  become 
encapsulated  larvae. 

Muscle  Trichince. — Tiedemann,  in  1822,  described  the  ovoid 
cysts  in  human  muscle.  Owen  named  the  parasite.  Leidy,  in  1845, 
described  it  in  the  p  g.  In  i860  Zenker  discovered  in  a  girl  both  the 
intestinal  and  muscle  forms,  and  established  their  connection  with 
the  specific  symptoms. 

Incidence. — Man  is  infected  by  eating  the  raw  or  not  completely 
cooked  flesh  of  trichinous  hogs,  which  contain  encapsulated  trichinae. 
The  capsules  are  digested  in  the  stomach  and  the  trichinae  set  free. 
They  pass  into  the  small  intestine,  and  about  the  third  day  become 


Fig.  268. 


-Trichina  spiralis  (greatly  enlarged):  a,  Female;  6,  male;  c,  embryo 
(after  Heller). 


sexually  mature.  On  the  sixth  or  seventh  day  the  embryos  are  fully 
developed.  The  young  produced  by  each  trichina  (female)  have  been 
estimated  at  several  hundred.  The  female  worm  penetrates  the  intes- 
tinal wall  and  the  embryos  are  probably  discharged  directly  into  the 
lymph-spaces,  and  thence  into  the  venous  system,  whence  they  reach 
the  muscles;  and  in  about  two  weeks  they  develop  into  the  full- 
grown  muscle  form.  A  myositis  is  produced  and  they  may  become 
encapsulated.  The  trichinae  may  live  therein  for  many  years.  Cal- 
cification may  occur  about  them.  One  must  remember  that  in  the 
hog  the  capsule  does  not  readily  become  calcified,  so  that  the  para- 
sites are  not  as  readily  visible  as  in  man.  Moreover,  an  apparently 
healthy  looking  animal  may  be  suffering  from  trichiniasis. 

The  intestinal  tricliince  are  visible  to  the  naked  eye — white  glistening 
worms  3  to  4  mm.  long;  and  the  male  half  this  size,  with  two  little 
projections  from  the  hind  end.  The  caudal  extremity  is  thicker  than 
the  head  (1-ig.  268). 


7IO 


DISEASES   OF   THE    STOMACH    AND    INTESTINES 


The  muscle  trichina  is  o.6  to  i  mm.  long  and  coiled  in  the  cap- 
sule.    It  has  a  pointed  head  and  rounded  tail  (Fig.  269). 

Symptoms. — As  a  rule,  a  few  days  after  eating  the  infected  flesh 
gastro-intestinal  disturbances  occur,  such  as  pain  in  the  abdomen, 
anorexia,  vomiting,  and  at  times  diarrhea.  The  attack  may  resemble 
cholera  nostras  or  even  typhoid  fever.  Invasion  symptoms  usually 
occur  between  the  seventh  and  tenth  days  or,  occasionally,  not  until 
the  end  of  two  weeks.  There  may  be  fever,  intermittent  or  remit- 
tent, even  to  102°  to  104°  F.     Chills  are  not  common. 

Pain  occurs  in  the  muscles  on  pressure  and  movement,  also  swell- 
ing of  the  muscles.  There  may  be  difficulty  in  chewing  and  swallow- 
ing. Dyspnea  may  be  present  from  involvement  of  the  intercostal 
muscles  and  diaphragm.  Edema,  especially  about  the  eyes,  is  an 
important  symptom.     Sweating,  itching,  and  urticaria  occur.     The 

general  nutrition  is  disturbed  and  the 
patient  becomes  anemic  and  emaciated. 
In  cases  with  severe  infection,  there 
may  be  dehrium,  tremor,  and  dry 
tongue,  suggestive  of  typhoid  fever. 
Bronchitis,  pleurisy,  pneumonia,  poly- 
uria, or  albuminuria  may  occur. 

lyCukocytosis,  especially  marked  eosin- 
ophilia,  is  diagnostic. 

Eosinophilia,  edema  of  the  eyelids, 
dyspnea,  swelling,  and  tension  of  the 
muscles  are  at  once  suggestive.  The 
presence  of  trichinae  in  the  stools  and 
muscles  is  conclusive.  The  muscle  can 
be  incised  under  cocain  injection  and 
the  cyst  examined. 

The    disease  has  proved  fatal  in  a 

number  of  cases. 

Prognosis. — This  depends  on  the  intensity  of  -the  infection.     Mild 

cases  may  recover  in  two  weeks.     The  mortality  has  ranged  as  high 

as  30  per  cent.     Early  diarrhea  is  favorable  to  evacuate  infected  pork. 

Prophylaxis.— Fork,  such  as  ham,  sausage,  etc.,  should  always  be 

thoroughly  cooked   before  eating.     Proper    inspection    of    hogs   is 

important. 

Treatment.— ImmedieLte  lavage,  if  infected  pork  is  suspected  and 
the  case  is  seen  early.  Evacuation  of  the  bowel  by  calomel,  gr.  x 
(0.6),  or  a  saline  cathartic.  Thymol,  santonin,  male  fern,  kamala, 
and  turpentine,  have  all  been  recommended  as  vermifuges  in  the 
early  stage.  Glycerin  in  large  doses  internally  is  said  to  be  destructive 
of  the  worm.  Later,  the  treatment  is  symptomatic  and  the  strength 
is  to  be  supported.  Urotropin,  in  gr.  x  (0.6)  doses  four  times  a  day, 
I  believe  of  possible  value  during  the  early  stages.  It  is  preferable 
to  combine  it  with  equal  doses  of  sodium  benzoate. 


Fig.    269. — Fresh    muscle    tri- 
chinae (Mosler  and  Peiper) . 


INDEX 


Abdomen,  anatomic  landmarks  of,  47 
auscultation  of,  55 
blood-vessels  of,  49 
examination  of,  47 
inspection  of,  49 
mensuration  of,  51 
palpation  of,  50 

reinforced,  50 
percussion  of,  52 

sources  of  error,  54 
perforation  into,  in  intestinal  cancer, 

564 
protrusion  of,  intestinal  disease  and, 

395 

regions  of,  48 

topographic  anatomy  of,  48,  55 
Abdominal  arteriosclerosis,  455 

belt,  Kilmer's,  175-179 
Rose's,  170-175 
Rose  water's,  175 

cavity,  sounds  in,  55 

muscles,  functions  of,  343,  344 

pressure,  increase  of,  in  treatment  of 
gastroptosis,  356 

relaxation,    34.       See    also  Gastrop- 
tosis. 

viscera,  mechanical  methods  of  sup- 
porting, 170 
Abscess  formation  in  appendicitis,  596, 
603 
symptoms,  597 

in  diverticulitis,  631,  632 

of  liver  in  amebic  dysentery,  509 
in  bacillary  dysentery,  524 

of  stomach,    188.      See  also  Gastritis, 
phlegmonous. 

subphrenic,  terminations  of,  220 
Absolute  hepatic   dulness,  upper  limit 

of,  59 
Absorption  in  hyperchlorhydria,  283 
Absorptive  function  of  stomach,  deter- 
mination,  121 


Acetic  acid  in  gastric  contents,  103 
Acholic  feces,  414 
Achroodextrin,  test  for,  106 
Achylia  gastrica,  203 

absorption  in,  207 

carcinoma  and,  differentiation,  117 

chronic  gastritis  and,    differentia- 
tion, 195 

conditions  caused  by,  207 

course  of,  207 

diagnosis,  206,  207 

diet  in,  139,  208 

etiology,  203,  204 

gastralgia  and,  differentiation,  367 

gastric  analysis  in,  206 

cancer  and,  differentiation,  207, 

259 
ulcer  and,  214 
history,  203 

intestinal  irrigation  in,  210 
morbid  anatomy,  204 
motor  function  in,  207 
prognosis  of,  207 
putrefaction  in,  treatment,  210 
symptoms,  204 
temporary,  203,  204 
treatment,  208 
Acid  gastritis,  190,  194 

hyperchlorhydria  and,  differentia- 
tion, 285 
treatment,  195 
salts,  Topfer's  test  for,  99,  100 
Acne  rosacea,  stomach  functions  in,  391 

simplex,  stomach  functions  in,  391 
Acute  febrile  diseases,   stomach  func- 
tions in,  387 
Adenocarcinoma  of  stomach,  242 
Adenoma  of  intestines,  571 
Adenomyoma  of  intestines,  560 
Adhesion      symptom,     Gersuny's,     of 

fecal  tumor,  463 
Adhesive  belt,  Rose's,  170-175 
711 


712 


INDEX 


Adhesive   strapping  in   intestinal    dis- 
eases, 440 
to  support  viscera,  170 

Adler's  test  for  blood  in  gastric  con- 
tents and  stool,  114 

Adnexa,  uterine.  Head's  zone  for,  615 

Aerophagy,  451 

Agar-agar  in  constipation,  470 

Air,  inflation  of  intestines  with,  406 
of  stomach  with,  78 
swallowing,  451 

Akoria,  362 

Albumin,  absorption  of,  39 
in  feces,  411,  412 
in  food,  replacing  of,  135 

Albuminates,  absorption  of,  39 

Albumoses,  absorption  of,  39 

Alcohol  as  food,  136 

Aldehyd,  test  for,  102 

Alimentary  glycosuria,  40 

Alimentation,  time  required  for,  423 

Alkaline-saline  waters  in  chronic  gastri- 
tis, 199 

Alkalis  for  removing  mucus  in  chronic 
gastritis,  196 

Allingham's      operation      for      hemor- 
rhoids, 585 

Allotriophagia,  362 

Almond  oil  subcutaneously,  138 

Aloes  in  constipation,  470 

Aloin  test  for  blood,  Klunge's,  115 

Amebae,  681 

dysenterise,  503,  504 
encysted,  505 
isolation  of,  503,  504 
in  gastric  contents,  117 

Amebic     dysentery,     503.     See     also 
Dysentery,  amebic. 

Amebiosis,    intestinal,    503,    511.     See 
also  Dysentery,  amebic. 

Ampulla  of  rectum,  32 

Amylaceous  dyspepsia,  treatment,  445 

Amyloid  intestinal  ulcers,  547 
symptoms,  551 
treatment,  553 

Amylopsin,  37 
test  for,  1 1 3 

Anacidity,  diet  in,  139 

Anadenia  ventriculi,  191,  203.    See  also 
Achylia  gastrica. 

Anatomy  of  intestines,  22 
of  large  intestine,  29 


Anatomy  of  small  intestine,  26 

of  stomach,  17 
Anchylostoma     duodenale,     701.     See 

also  Uncinariasis. 
Anemia,  grave,  in  gastric  cancer,  per- 
nicious   anemia    and,    differentia- 
tion, 255 

in  gastric  ulcer,  treatment,  230 

in  uncinarial  dermatitis,  705 

miners',  701.  See  also  Uncinariasis. 

pernicious,  auto-intoxication  in,  448 
grave  anemia  in  gastric  cancer  and, 
differentiation,  255 

stomach  functions  in,  389 

treatment  of  constipation  in,  471 
Anesthesia  of  rectum,  669 
Aneurysm    of    celiac    axis,    cancer    of 
pylorus  and,  differentiation,  25S 

stomach  functions  in,  390 
Angina  abdominis,  angina  pectoris  and, 

differentiation,  455 
Angioma  of  intestines,  572 
Anguillata  intestinalis,  707 

stercoralis,  707 
Angustatio  ventriculi,  340 
Animal  and  vegetable  foods,  difference, 
127 

parasites,  intestinal,  681 
Ankylostoma  duodenale,  701.     See  also 

Uncinariasis. 
Anorexia  in  gastric  cancer,  245 

nervosa,  362 

transitory,  362 
Antidotes  for  poisoning,   187 
Antiperistalsis,  intermittent,  41 

physiologic,  41 
Antiperistaltic  restlessness  of  stomach, 

371 
Antiseptics  in  acute  amebic  dysentery, 

517 
Antrum  cardiacum,  340 
Anuria  in  intestinal  obstruction,  635 
Anus,  31 

fissure  of,  588 

hygiene  of,  in  hemorrhoids,  580 

inspection  of,  396 
Apepsinia,  T04 

Aperient  waters  in  constipation,  471 
Appendices  epiploicse  of  large  intestine, 

29 
Appendicitis,  591 

acute,  594,  595,  596 


INDEX 


713 


Appendicitis,  acute,  abscess  in,  603 
adhesions  in,  603 
blood  in,  605 

count  in,  605-607 
Blumberg's  sign  in,  601 
bowels  in,  602 
colic  in,  598 

treatment,  617 
constipation  in,  602 
diarrhea  in,  598,  602 
diet  in,  618 
etiology,  593 

fecal  accumulation  in,  617 
fibrin  increase  in,  605 
fulminating  type,  603 
gastro-intestinal  symptoms,  602 
hyperinosis  in,  605 
Illoway's  test  in,  601 
intestinal  symptoms  in,  602 
lavage  in,  617,  618 
leukocytosis  in,  605 
McBurney's  point  in,  599 
Meltzer's  method  of  palpation  in, 

601 
Morris'  point  in,  599,  600 
Munro's  point  in,  600 
muscular  rigidity  in,  599 
operation  in,  indications,  619 
pain  in,  598 

treatment,  617 
palpation  of  appendix  in,  599 
percussion  in,  599,  601 
polynuclear  count  in,  605,  606 
prognosis,  616 

pulse  in,  602 
rectal  examination  in,  602 
remote  effects,  607 
stomach  symptoms,  602 
symptoms,  597,  602 
temperature  in,  602 
tenderness  in,  599 
treatment,  616 

medical,  616 

operative,  619 
tumefaction  in,  603 
tumor  in,  602 

tympanites  in,  treatment,  617,  618 
types  of,  594,  595,  596,  603,  607 
vaginal  examination  in,  602 
age  and,  594 
bacteria  as  cause,  593 
Blumberg's  sign  in,  601 


Appendicitis,  catarrhal,  acute,  594 
simple,  595 

symptoms,  597 
symptoms,  597 
chronic,  595,  596 

diet  in,  618 

Edebohls'  palpation  in,  607,  608 

etiology,  607 

prognosis,  616 

treatment,  616 
clinical  classification,  595 
constipation  as  cause,  593 
diagnosis,  60S 
diet  in,  618 

differential  diagnosis,  608 
diffuse,  acute,  594 

symptoms,  597 
Edebohls'  palpation  in,  607,  608 
endo-,  594,  595 

symptoms,  597 
etiology,  593 

foreign  bodies  as  cause,  594 
gangrenous,  595,  596 

symptoms,  597 
Head's  zones  in  diagnosis,  609 
Illoway's  test  in,  601 
McBurney's  point  in,  599 
Meltzer's  method  of  palpation  in,  601 
Morris'  point  in,  599,  600 
Munro's  point  in,  600 
non-suppurative,  acute,  595 

symptoms,  597 
obliterative,  595 
operation  for,  indications,  619 
opium  in,  618 

pathologic  classification,  594 
perforative,  596 

symptoms,  597 
prognosis,  616 
purulent,  595,  596 

symptoms,  597 
sex  and,  594 
suppurative,  595 

acute,  596 

symptoms,  597 
treatment,  616 
urine  in,  602 
varieties,  594 

with  abscess  formation,  596 
symptoms,  597 
Appendicostomy     in     chronic    amebic 
dysentery,  520 


714 


INDEX 


Appendicular  colic,  598 
treatment,  617 
inflammation,     591.     See    also    Ap- 
pendicitis. 
Appendix  vermifojmis,  30 
blood-supply  of,  592 
cancer  of,  primary,  568 
diverticula  of,  625 
fibroid  degeneration  of,  597 
harmful      involutions     of,      auto- 
intoxication in,  608 
s5miptoms,  608 
Head's  zones  in  affections  of,  609, 

614 
inflammation    of,    591.     See    also 

Appendicitis. 
palpation  of,  599 
.  passing   transversely  to  left   iliac 
fossa,  633 
peculiarities  of,  592 
position  of,  591 
Appetite,  perversion  of,  361 
Areolar  coat  of  stomach,  19 
Armed  tapeworm,  686 
Arnold's  test  for  lactic  acid,  10 1 
Arsenic  in  gastric  cancer,  267 
Arsenic-poisoning,    intestinal    obstruc- 
tion and,  differentiation,  652 
Arterial  hemorrhoids,  575 
Arteries,  mesenteric,  embolism  of,  554. 
See  also  Emholisin. 
inferior,  occlusion  of,  557 
superior,  occlusion  of,  555 
thrombosis     of,     554.     See     also 
Thrombosis. 
of  cectun,  32 
of  colon,  32 
of  rectum,  32 
of  small  intestine,  24 
of  stomach,  21 
Arteriosclerosis,    auto -intoxication    in, 
446 
stomach  functions  in,  391 
visceral,  455 
Arthritis  deformans,  auto-intoxication 
in,  448 
intestinal  putrefaction  and,  44S 
stomach  functions  in,  391 
Artificial  feeding  in  intestinal  diseases, 

444 
Ascaris  lumbricoides,  697 
breath  in,  698 


Ascaris  lumbricoides,  diagnosis,  698 
migration  of,  698 
symptoms,  698 
treatment,  698 
mystax,  699 
Ascending  colon,  31 

palpation  of,  398 
Asiatic  pills,  230 
Aspirating  bulb,  93 

tube,  91 
Aspiration  of  gastric  contents,  91 
Boas'  bulb  for,  92 
.     method,  92 
bulb  for,  92,  93 
Ewald-Boas  expression  method, 

93 
Kemp's  method,  94 
Politzer  bulb  for,  92 
position  of  patient  and  operator, 

91 
steps  of,  93-95 
tube  for,  91 
testing  gastric  secretion  ^vithout,  108 
Asthma,  dyspeptic,  385 

auto-intoxication  in,  385 
Atonia  gastrica,  341.     See  also  Garfro/)- 

tosis. 
Atonic  constipation,  460 

treatment,  469 
Atonica  gastrica,  71,  303,  304,  372 
Atony  complicating  hyperchlorhydria, 
284 
of  intestines,  458.     See  also  Consti- 
pation. 
of  stomach,  71,  303,  372 
acute,  303 

treatment,  304 
chronic,  304,  305 

auto-rntoxication  in,  322,  323 
constipation  in,  treatment,  306 
electricity  in,  306 
medication  in,  305 
prognosis,  305 
Rose's  belt  in,  305 
symptoms,  304 
treatment,  305 
vibratory  massage  in,  305 
definition,  321 
etiology,  304 
gastric  analysis  in,  305 
physical  examination,  304 
spray  douche  in,  158 


INDEX 


715 


Atony  of   stomach,    third  degree,   341. 

See  also  Gastroptosis. 
Atrophic  gastritis,  191,   194,  203.     See 

also  Achylia  gastrica. 
Atrophy  of  mucosa  in  chronic  enteritis, 
488 

of  stomach,  191,  194,  203.     See  also 
Achylia  gastrica. 
Auerbach's  plexus,  25 
Auscultation,  52,  54 

of  abdomen,  55 

of  esophagus,  46 

of  intestines,  403,  404 

of  liver,  59 

of  stomach,  74 

scratch  method,  76 
Auto-intoxication,     acute     ectasy     of 
stomach  from,  311 

cyanotic,  450 

hydrogen  sulphid,  449 

in  acute  dilatation  of  stomach,  308, 

309 

gastritis,  181 

intestinal  catarrh,  478,  482 
in  arteriosclerosis,  446 
in  arthritis  deformans,  448 
in    atonic    dilatation    of     stomach, 

chronic,  322,  323 
in  botulism,  449 
in  chronic  enteritis,  490 

gastritis,  193 

obstruction  through  fecal  accumu- 
lation, 661 
in    combined    saccharobutyric    and 

indolic  putrefaction,  447 
in  constipation,  462,  464 
in  convulsions,  311,  338 
in  cutaneous  eruptions,  391 
in  diarrhea,  473 
in  dyspeptic  asthma,  385 
in  eczema,  391 

in  enterogenic  cyanosis,  450 
in  epilepsy,  311,  322,  338 
in  eruptions  of  skin,  391 
in  fever,  323 
in  furunculosis,  391 
in  gastric  tetany,  311,  336,  337 
in  gastroptosis,  345 
in  hepatic  irritation,  446 
in  indicanuria,  445,  446 
in  intestinal  dyspepsia,  444 
in  involution  of  appendix,  608 


Auto-intoxication  in  melancholia,  323, 

446 

in  migraine,  3 1 1 

in  mucous  colic,  676,  679 

in  muscle  fatigue,  448 

in  nephritis,  transient,  446 

in  neurasthenia,  323,  446 

in  paresis,  323 

in  pernicious  anemia,  448 

in  pruritus,  341 

in  pseudo-angina,  312 

in  putrefaction,  445,  446,  447 

in  strophulus  infantum,  391 

in  syncope,  323 

in  tachycardia,  312 

in  temperature,  323 

in  transient  heart  block,  446 

in  urticaria,  391 
Automassage  in  constipation,  467 
Awl-tail  worm,  699.     See  also  Oxyuris 

vermicularis. 

Bacillary  dysentery,   503,   520.     See 

also  Dysentery,  bacillary. 
Bacilluria  in  typhoid  fever,  533 

treatment,  541 
Bacillus    aerogenes    capsulatus,     con- 
stipation and,  464 
in  feces,  420 

intestinal  putrefaction  and,  447 
bificus,  38 

botulinus,  poisoning  from,  449 
coli,  38 

in  feces,  420 
odor  of  feces  and,  39 
dysenterise,  521 

Flexner-Harris  type,  521 
groups  of,  521 
Hiss-Russell  type,  521 
isolation  of,  522 
Shiga  type,  521 
types  of,  521 
various  strains  of,  521 
lactic  acid,  38,  420 
lactis  aerogenes,  38 

in  feces,  420 
typhosus,  528 

conveyance  of,  528,  529 
distribution  in  body,  529 
outside  body,  529 
vitality  of,  529 
Bacteria  in  feces,  419 


7i6 


INDEX 


Bacteria  of  intestine,  38 

Bacterium  coli  commune,  appendicitis 
and,  593 

Bainbridge's  modification  of  Beard's 
trypsin  treatment  of  gastric  cancer, 
269 

Balantidium  coli,  682 
diarrhea  from,  684 

Balloon  man,  456 

Barrel-shaped   abdomen   in   acute   ob- 
struction, 647 
in   chronic  intestinal   obstruction, 
658,  660 

Bassler's  stomach  electrode,  163 

Baths,  170 

in  typhoid  fever,  537 

Bath-tub,  Chambers'  portable,  538 

Bead  test  for  intestinal  motor  func- 
tions, 420 

Beard's  treatment  of  gastric  cancer, 
268,  269 

Beck's     treatment    of    gastric    cancer, 

275 
Bed,  elevation  of  foot  of,  in  gastropto- 

sis,  357 
Beef  tapeworm,  688 
Beef -juice,  136 
Beef -tea,  136 
Belching,  375 
Belts,  supporting,  170-179 
Benzidin   blood   test   for   gastric   con- 
tents, 114 

test  paper,  1 14 
Beverages,  chemic  composition  of,  132 
Bile,  function  of,  36 

in  empty  stomach,  113 

in  gastric  contents,  113 

in  vomit,  112 
Bile-pigment,  enteritis  and,  484 

in  feces,  413,  416 

sublimate  test  for,  425 
Bilharzia  hsematobia,  693 
Bilharziasis,  693 

treatment,  696 
Biliary  acids  in  feces,  413 

calculi  in  feces,  416 

colic,    hyperchlorhydria    and,  differ- 
entiation, 285 
Bismuth    subnitrate   internally  for  in- 
testinal examination,  405 

treatment  of  chronic  gastric  erosions, 
238 


Bisulphate    of    quinin    as    fluorescent 

medium  in  gastrodiaphany,  85 
Biuret  reaction  with  pepton,  103 
Black  wash  for  oxyuris   vermicularis, 

701 
Bladder  in  typhoid  fever,  530 

perforation  into,  in  rectal  cancer,  564 
Blood,  aloin  test  for,  115 
benzidin  test  for,  114 
fluke,  693 

treatment,  696 
in  appendicitis,  605 
in  feces,  410,  413,  419 
in  intestinal  cancer,  567 

ulcer,  552 
test  for,  1 14 
in  gastric  cancer,  247 

contents,  tests  for,  113 
in  typhoid  fever,  533 
in  uncinarial  dermatitis,  705 
in  vomit,  112,  211 

irritants    transmitted    in,     diarrhea 
from,  474 
treatment,  476 
Klunge's  aloin  test  for,  115 
occult,  114 

tests  for,  114 
of  pig,  heterologous,  in  gastric  cancer, 

274 
tests  for,  113— 115 
vomiting  of,  112,  211 
Weber's  modification  of  van  Deen's 
test  for,  115 
Blood-vessels  of   abdomen,    inspection 
of,  49 
of  intestines,  diseases  of,  554 
of  stomach,  19,  20 
Blumberg's  sign  in  appendicitis,  601 
Boas'  aspirating  bulb,  92 

method    of    aspirating    gastric    con- 
tents, 92 
of  diagnosing  catarrh  of  large  in- 
testine, 483 
of  eliciting  splash  in  intestines,  400 
nutritive  rectal  enema,  137 
test  breakfast,  90 

for  free  hydrochloric  acid,  97 
for  lactic  acid,  102 
meal  for  motor  power,  122 
Boas  and  Ewald's  method  of  express- 
ing gastric  contents,  93 
test  breakfast,  90 


INDEX 


717 


Boas  and  Moerner's  test  for  free  hydro- 
chloric acid,  106 
Boas-Oppler  baciUi   in  gastric  cancer, 

254,  255 
in  gastric  contents,  117,  119 

Boldireff's  oil  test  meal  to  secure  tryp- 
sin, 420 

Bone-marrow  in  typhoid  fever,  530 
in  uncinarial  dermatitis,  705 

Bones  in  typhoid  fever,  533 

Borborygmi,  404 

Bothriocephalus  cordatus,  690 
latus,  689 

s)rmptoms,  686 

Botulism,  449 

auto-intoxication  in,  449 

Bougie,  esophageal,  divisible,  250 
rectal,  401 

Bouillon,  136 

Brand  treatment  of  typhoid  fever,  537 

Brandt's  method   of  kidney  massage, 

357 
Bread,  636 

Breakfast  dietary,  128 
Brewer's  point,  68 
Broths,  meat,  136 

pastry,  and  solid  food  with  milk  diet, 

133 
Brunner's  glands,  27 
Bulb-compression  method  of  spraying 

stomach,  157 
Bulimia,  360 
Bunches,  703 

Burns,     cutaneous,     intestinal     ulcers 
from,  546 
symptoms,  551 
treatment,  553 
Butter,  136 

meat,  pastry,  and  soups  with    milk 
diet,  134 
Buttermilk,  136 

Cachexia,  diverticula  and,  627 

in  gastric  cancer,  246 
Calculi,  biliary,  in  feces,  416 

fecal,  in  feces,  416 

intestinal,  in  feces,  416 

pancreatic,  in  feces,  416 

renal,  gastralgia  and,  differentiation, 
368 
Calomel  in  acute  enteritis,  484,  485 

in  constipation,  471 


Calorie,  124 
large,  124 
small,  124 

table,  Chittenden's,  126 
value  of  food,  1 24 
calculating,  132 
Cancer  atrophicans,  243 
fragments  in  feces,  410 
of  appendix,  primary,  568 
of  body  of  stomach,  251 
of  cardia,  249 

diagnosis,  249—251 

dysphagia  in,  249 

esophageal  examination  in,  250 

physical  examination,  249 

stricture  of  esophagus  in,  250 
of  duodenum,  565 
of  gall-bladder,   gastric  cancer  and, 

differentiation,  259 
of  ileum,  566 
of  intestines,  551,  559 

age  and,  559 

blood  in  feces  in,  567 

carcinoma  of  liver  from,  560 

colic  in,  566 

constipation  in,  566 

course,  569 

diagnosis,  569 

diarrhea  in,  563,  566 

diet  in,  570 

differential  diagnosis,  567 

etiology,  559 

exploratory  laparotomy  in,  569 

feces  in,  563,  567 

from  diverticulitis,  632 

mimicry  of,  in  diverticulitis,  630 

mobility  of  tumor,  563 

morbid  anatomy,  560 

operations  for,  569 

pain  in,  566 

perforation  in,  564 
into  abdomen,  564 
into  bladder,  564 
into  stomach,  564 
into  uterus,  564 
into  vagina,  564 

peritonitis  from,  562,  564 

physical  signs,  563 

prognosis,  569 

pus  in  feces,  567 

secondary  changes,  561 

sex  and,  559 


7i8 


INDEX 


Cancer  of  intestines,  situation  of,  560 

symptoms,  551,  562 
due  to  position,  565 
local,  566 

treatment,  553,  569 

trypsin  treatment,  570 

tumor  in,  567 
of  jejuntun,  566 

of  liver  from  intestinal  cancer,  560 
of  pylorus,  251 

aneurysm  of  celiac  axis  and,  differ- 
entiation, 258 

partial  gastrectomy  for,  263 
of  rectum,  568 

hemorrhoids  and,  568 

perforation  into  bladder  in,  564 
into  vagina  in,  564 

treatment,  569 
of  stomach,  240 

achylia   gastrica  and,    differentia- 
tion, 117,  207,  259 

age  and,  240 

anorexia  in,  245 

apparent  tumors  and,  differentia- 
tion, 255 

arsenic  in,  267 

atrophicans,  243 

Beck's  treatment,  275 

blood  in,  247 

Boas-Oppler  bacilli  in,  254,  255 

bowels  in,  275 

cachexia  in,  246 

cancer  vaccine  in,  274 

carcinoma    of    gall-bladder    and, 
differentiation,  259 

chronic  gastritis   and,  differentia- 
tion, 195 

Coley's  fluid  in,  274 

colloid,  242 

coma  in,  249 

condurango  in,  267 

constipation  in,  249 
treatment,  275 

cylindric-celled,  242 

diagnosis,  251,  254 
differential,  255 
exploratory  laparotomy  in,  261 
laboratory,  251 

diarrhea  in,  treatment,  275 

diet  in,  138,  265 

drugs  for,  266 

duration,  260 


Cancer   of   stomach,  ectasia   in,    treat- 
ment, 274 

edema  in,  249 

emaciation  in,  246 

engrafted  on  ulcer,  257 

enlarged  lymph-glands  and,  differ- 
entiation, 260 

erysipelas  toxin  in,  274 

etiology,  240 

eventration  treatment  of,  274 

expiration  fixation  of  tumor  in,  248 

fibrolysin  in,  267 

fibrous,  242 

fluorescein  in  treatment,  265 

frequency,  240 

gastralgia  and,  differentiation,  367 

gastrectomy  for,  partial,  263 

gastric  analysis  in,  251 

ulcer  and,   differentiation,   221, 
222 

gastritis  and,  differentiation,  259 

gastro-enterostomy  for,  264 

gastrostomy  for,  264 

grave  anemia  in,  pernicious  anemia 
and,  differentiation,  255 

hematemesis  in,  246 
treatment,  274 

heredity  and,  240 

heterologous  blood  of  pig  in,  274 

hydrochloric  acid  in,  252 

hyperchlorhydria  in,  252,  253 

inflation  in,  248 

inspection  in,  247 

lactic  acid  in,  253 

laparotomy  in,  exploratory,  261 

location,  244 

loss  of  weight  in,  246 

medical  treatment,  265 

medullary,  242 

mesenteric  growths  and,   differen- 
tiation, 260 

metastases  in,  244,  249 

methylene-blue  in,  268 

morbid  anatomy,  242 

multiple  neuritis  in,  249 

nervous  dyspepsia  and,  differentia- 
tion, 383 
gastralgia    and,    differentiation, 

259 
pain  in,  245 

treatment,  274 
palliative  operation,  264 


INDEX 


719 


Cancer  of  stomach,  palpation  in,  247 
parasitic  origin,  241 
percussion  in,  247 
perforation  in,  244,  249 
peritoneal   growths   and,    differen- 
tiation, 260 
prognosis,  260 
pus  in,  254 
race  and,  240 
radical  operation  in,  263 
radium  for,  265 
resection  in,  263 
respiratory  motility  in,  248 
Rontgen  rays  in  diagnosis,  255 

in  treatment,  265 
scirrhus,  242 

sclerosis  and,  differentiation,  255 
secondary     changes     in     mucous 

membrane,  243 
sex  and,  240 
shape  of  organ  in,  244 
sodium  iodid  in,  266 
stenosis  and,  differentiation,  259 

of  cardia  in,  treatment,  275 
stomachics  in,  267 
surgical  treatment,  261 
symptoms,  245 

due  to  location,  249 
syphilis  and,  differentiation,   255 
syphilitic    cirrhosis    of    liver    and, 
differentiation,  256 
stenosis  of  pylorus  and,   differ- 
entiation, 256 
temperature  in,  249 
test  breakfast  in,  252 
tetany  in,  249 
thiosinamin  in,  267 
thrombosis  in,  249 
thymus  in  treatment,  273 
transillumination  in,  248 
treatment,  261 
medical,  265 
surgical,  261 
trypsin,  253,  268,  269 
Tremoliere's  solution  in," 274 
trypsin  treatment,  253,  268,  269 
tumor  in,  247 
types  of  growth,  243 
ulcer  and,  differentiation,  259 
urine  in,  249 
varieties,  242 
vomiting  in,  246 


Cancer  of  stomach,  vomiting  in,  treat- 
ment, 274 
vomitus  in,  252 
vaccine,  274 
Cane-sugar,  absorption  of,  40 
Canine  hunger,  360 

Cannon-ball   massage   in  constipation, 
467 
with  handle,  467 
with  screw  cap,  467 
Capillary  hemorrhoids,  575 
Caput  coli,  29.     vSee  also  Cecum. 

medusae,  49 
Carbohydrates,  absorption  of,  40 
digestibility  of,  136 
in  feces,  412 

fermentation  test  for,  425 
liquid,  with  milk  diet,  133 
Carbolic  acid  injection  for  hemorrhoids, 

584 
Carbon  dioxid,  test  for,  no 
Carbonated  bath,  170 
Carbonic  acid  bath  in  mucous  colic,  677 
gas  for  tenesmus  in  amebic  dysen- 
tery, 519 
generator,  Rose's,  406,  407 
inflation  of  intestines  with,  406 
of  stomach  with,  77 
Carcinoma.     See  Cancer. 
Carcinomatosum,  569 
Cardia,  cancer  of,  249.     See  also  Cancer 
of  cardia. 
insufficiency  of,  375 
spasm  of,   373.     See  also  Spasm  of 

cardia. 
stenosis  of,  in  cancer,  treatment,  275 
Cardiac  glands  of  stomach,  20 

orifice  of  stomach,  17 
Cardialgia,  365.     See  also  Gastralgia. 
Cardioptosis,  353 
Cardiospasmus,   373.     See  also  Spasm 

of  cardia. 
Carlsbad  salts,  Wolff's,  199,  290 
Cascara  sagrada  in  constipation,  469 
Casein  lest  for  pepsin,  104 
Castor  oil  in  constipation,  471 
Catarrh,  drunkard's,  190 

intestinal,  478.     See  also  Euteritis. 
of  stomach,  180.     See  also  Gastritis. 
Catarrhus  atrophicans,  203.     See  also 
Achylia  gastrica. 
intestinalis,  478.     See  also  Enteritis. 


720 


INDEX 


Cauterization     of     hemorrhoids     with 

fuming  nitric  acid,  585 
Cecostomy,  Gant's  modification,  520 

in  chronic  amebic  dysentery,  520 
Cecum,  29 

arteries  of,  32 

inflammation  of,  591 

lymphatics  of,  32 

nerves  of,  32 

palpation  of,  398 

veins  of,  32 
Celiac    axis,    aneurysm    of,    cancer    of 

pylorus  and,  difl'erentiation,  258 
Cercomonas  intestinalis,  681 
Cereals,  chemic  composition  of,  131 
Cerebral  disease,  gastralgia  from,  366 
Cestodes,  685 

description,  686 

treatment,  690 
Chambers'  portable  bath-tub,  538 
Charcot-Iycyden  crystals  in  feces,  418 
Chemic  composition  of  foods,  130 
Chenopodium  for  ascaris  lumbricoides, 

699 
Chewing  the  cud,  376 
Chittenden's  calorie  table,  126 
Chlorosis,     Egyptian,     701.  ,  See    also 
Uncinariasis. 

stomach  functions  in,  389 
Cholelithiasis,  gastric  ulcer  and,  differ- 
entiation, 221 
Cholera  nostras,  478.     See  also  Enter- 
itis, acute. 

table,  Lee's,  430 
Cholesterin  in  feces,  416 
Chronic  febrile  diseases,  stomach  func- 
tions in,  388 
Chvostek's  symptom  in  gastric  tetany, 

337 
Chylangioma  of  intestines,  572 
Chyme  within  stomach,  determination, 

III 
Chymosinogen,  105 

Circulatory  organs  in  typhoid  fever,  531 
Circumpapillary  cancer  of  duodenum, 

565 
Circumscribing  gastrodiaphane,  83,  84 
Cirrhosis   of   liver,    gastric   ulcer   and, 
differentiation,  223 
syphilitic,      gastric     cancer     and, 
differentiation,  256 
of  stomach,  syphilitic,  393 


Cirrhosis  ventriculi,  191,  192,  204 

Clapotage,  400 

Coccidia,  681 

Cocoanut  for  tapeworm,  691 

Coffee,  136 

Cold,  168 

diarrhea  from,  475 
Coley's  fluid  in  gastric  cancer,  274 
Colic,  669 
fecal,  463 

intestinal,  453.     See  also  Enteralgia. 
mucous,  672 

abdominal  support  in,  677 

age  and,  672 

auto-intoxication  in,  676,  679 

carbonic  acid  bath  in,  677 

catarrh  in,  treatment,  679 

cramps  in,  treatment,  676 

diet  in,  676,  680 

enteroclysis  in,  676,  677 

enteroptosis  and,  674 

etiology,  672,  674 

exercise  in,  680 

fattening  in,  677 

history,  672 

hydrotherapy  in,  677 

in  newborn,  675 

in  young,  675 

irrigation  in,  676,  679 

medication  in,  676 

mixed,  treatment,  678 

operation  in,  680 

other  diseases  and,  674 

pathology,  673 

prognosis,  676 

pure,  674 

removal  of  mucus,  679 

researches,  674 

secondary  to  colitis,  674  ^ 

sex  and,  672 

surgical  treatment,  680 

symptoms,  673 

theories  of,  672 

tonics  in,  679 

treatment,  676 
Colitis,  acute  catarrhal,  diagnosis,  483 
chronic,     487.     See     also     Enteritis, 

chronic. 
in  typhoid  fever,  treatment,  541 
ulcerative,  550 

symptoms,  551 

treatment,  553 


INDEX 


721 


Colloid  carcinoma  of  stomach,  243 
Colocynth  in  constipation,  471 
Colon,  arteries  of,  32 
ascending,  31 

auscultatory  percussion  of,  402 
cancer  of,  perforation  into  stomach 

in,  564 
descending,  31 
dilatation  of,  456 

congenital  primary,  456 
diseases  of,  Tiirck's  gyromele  in,  164 
hypertrophy     of,     with     congenital 

dilatation,  456 
inflation  of,  with  water,  408 
location  of,  by  Rontgen  rays,  405 
lymphatics  of,  32 
nerves  of,  32 
palpation  of,  398 
position  of,  inflation  in  determining, 

407 
transverse,  31 

position  of,  19 
tuberculosis  of,  549 
ulcers  of,  549,  550 
upper,  catarrh  of,  diagnosis,  483 
veins  of,  32 
Colonic  massage  bags,  439 

nebulizer,  439,  440 
Colon-tube,  430 

for  high  enema,  429 
Color  tests  for  free  hydrochloric  acid,  97 
Columns  of  Morgagni,  33 
Coma  in  gastric  cancer,  249 
Combined  hydrochloric  acid,   Topfer's 

test  for,  99 
Compress,  Priessnitz's,   168 
Compression  of  intestines,  636 

mechanism,  639 
Concretions  in  feces,  415,  416 
Condom  as  cooler  in  hemorrhoids,  581 
Condurango  in  gastric  cancer,  267 
Condyloma  in  hemorrhoids,  578 
Congo  paper,  preparation  of,  107 

tests   for   free    hydrochloric    acid, 
106,  107 
Connective-tissue  fibers  in  feces,  410 
Constipating  foods,  443 
Constipatio  alvi,  458.     See  also  Consti- 
pation. 
Constipation,  458 
agar-agar  in,  470 
aloes  in,  470 
46 


Constipation,  aperient  waters  in,  47 1 
appendicitis  and,  593 
atonic,  460 

needle  douche  in,  439 

treatment,  469 
auto-intoxication  in,  462 
automassage  in,  467 
bacillus    aerogenes   capsulatus   and, 

464 
calomel  in,  471 
cannon-ball  massage  in,  467 
cascara  sagrada  in,  469 
castor  oil  in,  471 
classification,  458 
colocynth  in,  471 
definition,  458 
diagnosis,  464 
diarrhea  with,  474 

treatment,  476 
diet  in,  465 
diverticula  and,  627 
electric  irrigation  in,  recurrent,  468 

massage  in,  hot-and-cold,  467 
electricity  in,  468 
enemata  in,  468 
enteroclysis  in,  468 
etiology,  458 
fecal  colic  in,  463 
treatment,  471 

fever  in,  464 

tumors  in,  463 
treatment,  471 
food  laxatives  in,  465,  466 
from  motor  disturbances,  459 
glycerin  iniections  in,  469 
gymnastics  in,  467 
hemorrhoids  and,  576 
hydrotherapy  in,  468 
hygienic  treatment,  465 
in  acute  gastric  ectasy,  314 

treatment,  319 
in  anemics,  treatment,  471 
in  appendicitis,  602 
in  atonic  ectasy  of  stomach,  treat- 
ment, 334 
in  auto-intoxication,  462,  464 
in  chronic  enteritis,  490 
diet  in,  495 
treatment,  496 

gastric  atony,  treatment,  306 

gastritis,  treatment,  201 

obstruction,  659 


722 


INDEX 


Constipation  in  gastric  cancer,  249 
treatment,  275 

in  gastroptosis,  treatment,  358 

in  hemorrhoids,  treatment,  579 

in  hyperchlorhydria,  291 

in  intestinal  cancer,  566 

in  typhoid  fever,  539 

injections  in,  468 

jalap  in,  471 

laxatives  in,  469 

licorice  powder  in,  470 

massage  in,  466 

medication  in,  469 

nervous  symptoms,  463 

olive  oil  in,  466,  470 

orthopedics  in,  469 

physical  treatment,  466 

podophyllin  in,  470 

prescriptions  for,  470 

prognosis,  465 

prophylaxis,  465 

regulin  in,  470 

rhubarb  in,  470 

Rose's  belt  in,  469 

spastic,  460 
treatment,  469 

symptoms,  461 
nervous,  463 
.  syrup  of  figs  in,  470 

tamarinds  in,  470 

termination,  462 

training  of  patient,  465 

treatment,  465 

vertigo  in,  463 

vibratory  massage  in,  467 
Constitutional  diseases,  intestinal  ulcers 
in,  550 
symptoms,  551 
treatment,  553 
Convulsions,  acute  ectasy  of  stomach 
from,  311 

auto-intoxication  in,  311,  338 

in  ectasy  of  stomach,  338 
Coproliths  in  feces,  416 
Coprostasis  in  acute  gastric  ectasy,  314 
Corsets  for  abdominal  support,  179 

in  gastroptosis,  355 
Costovertebral  angle,  tenderness  at,  68 
Counterirritation,  1 70 
Covered  hepatic  dulness,  59 
Crescentic  fold  of  vermiform  appendix, 
31 


Croton  oil  for  tapeworm,  692 
Cruveilhier's    disease,    212.     See    also 

Ulcer  of  stomach. 
Crypts  of  Lieberkiihn  in  acute  enteritis, 

480 
Crystals  in  feces,  418 
Cul-de-sac  of  stomach,  greater,  17 
Curvatures  of  stomach,  18 
Cusso  for  tape-worm,  691 
Cutaneous  burns,  intestinal  ulcers  from, 

546 
symptoms,  551 
treatment,  553 
eruptions,  auto-intoxication  in,  391 
Cyanosis  during  passing  of   stomach- 
tube,  144 
enterogenic,  450 

auto-intoxication  in,  450 
Cyclic  vomiting  in  children,  378 
Cylindric  rectal  bougie,  401 
Cylindric-celled  cancer  of  stomach,  242 
Cynorexia,  360 

Cysts  in  amebic  dysentery,  509 
of  intestines,  gas,  573 

Dairy  products,  chemic  composition  of, 

131 
Davainea  Madagascariensis,  689 
Davidson's  syringe  to  inflate  intestines 

with  air,  407 
Dawbarn's  method  of  lavage,  150 
Debove's  meat  powder,  137,  209 
Deglutible  electrode,  Einhorn's,   162 
Deglutition  sounds,  81 
Dehio's  method   of   determining  posi- 
tion of  stomach,  78,  89 
Demulcents  in  toxic  gastritis,  187 
Denayer's  peptone  preparation,  133 
Dermatitis,  uncinarial,  703.     See   also 

Uncin arial  dermatitis. 
Descending  colon,  31 
palpation  of,  398 
Desmoid     test    for    gastric    secretion, 

Sahh's,  108 
Dextrin,  test  for,  106 
Diabetes,  stomach  functions  in,  390 
Diaphragmatic  hernia,  638,  639 
Diarrhea,  472 

acute,  478.     See  also  Enfcritis,  acute. 

auto-intoxication  in,  473 

cathartica,  473 
treatment,  476 


INDEX 


723 


Diarrhea,  classification,  473 
definition,  472 
dyspeptica,  473 

treatment,  476 
entozoica,  474 

treatment,  476 
etiology,  472 

from  balantidium  coli,  684 
from  cold,  475 
from  foods,  473 
from  gastric  disturbances,  473 
from  intestinal  parasites,  474,  476 
from  irritants  transmitted  in  blood, 

474 
treatment,  476 
from  irritation  of  bowel  contents,  473 
from  laxatives,  treatment,  476 
from  parasites,  474,  476 
from  wet,  475 
gastrica,  473 

treatment,  476 
in  appendicitis,  598,  602 
in  cancer  of  intestines,  563,  566 
in  chronic  enteritis,  490,  491 
diet  in,  495 

obstruction,  659 
in  gastric  cancer,  treatment,  275 
in  intestinal  ulcer,  552 
in  typhoid  fever,  539 
nervosa,  474,  667 

treatment,  476 
opiates  in,  477 
stercoralis,  474 

treatment,  476 
treatment,  475 
vicarious,  475 
with  constipation,  474 

treatment,  476 
Diastase  in  feces,  415 
Diazo-reaction  in  typhoid  fever,  533 
Diet,  124 

in  achylia  gastrica,  139,  208 
in  acute  amebic  dysentery,  516 

enteritis,  486 

gastric  ectasy,  318 

gastritis,  138 
in  anacidity,  1 39 
in  appendicitis,  618 
in  atonic  ectasy  of  stomach,  329 
in  bacillary  dysentery,  527 
in  cancer  of  stomach,  138,  265 
in  chronic  amebic  dysentery,  519 


Diet  in  chronic  enteritis,  495 

gastric  atony,  305 

erosions,  238 
gastritis,  139,  197 
intestinal  obstruction,  663 

in  constipation,  465 

in  disease,  138 

in  ectasia,  139 

in  gastric  ulcer,  226 

in  gastroptosis,  139,  356 

in  gastrosuccorrhea  continua  chron- 
ica, 300 
periodica,  296 

in  health,  124 

in  hemorrhoids,  579 

in  hyperacidity,  139 

in  hyperchlorhydria,  286 

in  hypersecretion,  139 

in  intestinal  cancer,  570 
diseases,  442 
indicanuria,  446 
ulcers,  554 

in  motor  disturbances,  139 

in  mucous  colic,  676,  680 

in  nervous  dyspepsia,  139,  383 

in  pyloric  stenosis,  138 

in  simple  acute  gastritis,  184 

in  stenotic  ectasy  of  stomach,  335 

in  stricture  of  stomach,  138 

in  subacidity,  139 

in  typhoid  fever,  535 

in  ulcer  of  stomach,  138 

Russell's,  in  gastroptosis,  356 

scale,  Leube's,  135 

test,    to   determine   intestinal   func- 
tions, 421 

to    increase    abdominal    pressure    in 
gastroptosis,  356 
Dietaries,  128 

breakfast,  128 

dinner,  128 

lunch,  1 28 

milk,  with  carbohydrates  in  mushes 
and  soups,  133 
with  liquid  carbohydrates,  133 
with     pastry,    butter,    meat,    and 

soups,  134 
with     solid     foods,     pastry,     and 
broths,  133 

non-irritating,  134 

standard,  125 

von  Noorden's,  132-134 


724 


INDEX 


Dietl's  crisis  in  gastroptosis,  treatment, 
358 
in  nephroptosis,  345,  352 
Dieulafoy's  iilcer  of  stomach,  235 
Digestibility  of  food,  134 
Leube's  scale,  135 
Penzoldt's  scale,  135 
Digestion,  ferments  of,  34 
function  of  intestines  in,  34 

of  stomach  in,  34 
gastric,  35 
intestinal,  36 
physiology  of,  34 

starch,    105.     See  also  Starch  diges- 
tion. 
Dilatation     complicating     hyperchlor- 
hydria,  284 
of  colon,  456 

congenital  primary,  456 
of  intestines  in  typhoid  fever,   pos- 
tural treatment,  539 
of  sphincters  for  hemorrhoids,  584 
of  stomach,  306.     See  also  Ectasy  of 
stotnach. 
Dilator,  Roberts',  584 
Dinner  dietary,  128 
Diphtheria   toxin,    gastric   ulcer  from, 

213 
Diphtheritic  dysentery,   501,   503,   523 
See  also  Dysentery,  diphtheritic. 
gastritis,  181 
Dipping,  51 

Dipylidium  caninum,  690 
Dislocation  of  stomach,  341 
Distoma  hsmatobium,  693 
hepaticum,  692 
lanceolatum,  693 
Distomiasis,  692 
hemic,  693 

treatment,  696 
intestinal,  693 
treatment,  696 
Diverticula  of  appendix,  625 
of  intestines,  623 

absence  of  fat  and,  627 
acquired,  623,  624 

frequency,  625 
age  and,  627 
anatomy,  626 
aperture  of,  626 
cachexia  and,  627 
congenital,  623,  624 


Diverticula    of    intestines,   connective 
tissue  around  vessels  and,  628 
constipation  and,  627 
contents,  626 
etiology,  626-629 
false,  624 

flatulence  as  cause,  627 
foreign  bodies  in,  632 
inflammation    of,    627.     See    also 

Diverticulitis. 
Meckel's,  24,  624 

strangulation  by,  637 
muscular   deficiency   of   gut   wall 

and,  629 
obesity  and,  627 
occurrence,  625 
perforation  of,  631 
pressure  from  within  bowel  and, 

627 
pulsion,  627 
relation  of,  to  points  of  entry  of 

vessels  through  gut  walls,  627 
secondary  pathologic  processes  in, 

629 
sex  and,  627 
sigmoid  flexure  and,  627 
size,  626 

of  vessels  and,  628 
structure   of    intestinal   wall   and, 

627 
true,  623,  624 
Diverticulitis,  620 
abscess  in,  631,  632 
acute,  630 

diagnosis,  634 
symptoms,  632 
treatment,  634 
adhesive,  630,  631 
as  part  of  general  peritonitis,  630 
catarrhal  acute,  630 
chronic,  630 
diagnosis,  634 
symptoms,  632 
treatment,  634 
classification,  630 
clinical  aspects,  632 
diagnosis,  634 

Eisendrath's  classification,  630 
enterovesical  fistulous,  630 
etiology,  626-629 
fistulse  in,  submucous,  631 
vesicocolic,  633 


IMDEX 


725 


Diverticulitis,  foreign  bodies  and,  632 

gangrenous,  acute,  630 

history,  620 

hyperplastic,  chronic,  630 

intestinal  obstruction  in,  633 

left-sided  tumor  in,  632 

mesenteritis  in,  632 

metastatic  suppuration  in,  632 

mimicry  of  carcinoma  in,  630 

pathology,  629 

perforation  in,  631,  632 
of  hernial  sac,  632 

perforative,  acute,   630 

peridiverticulitis     and,     distinction, 
621,  623 

peritonitis  from,  local  chronic,  632 
in,  perforative,  631,  633 

stenosing,  chronic,  630 

stenosis  and  obstruction  in,  630 
carcinoma  and,  differentiation,  631 

submucous  fistulse  in,  631 

symptoms,  632 

Telling's  classification,  630 

treatment,  634 

tumor  formation  in,  630,  632 

types,  630 
Divisible  esophageal  bougie,  250 
Dochmius   duodenalis,    701.     See   also 

Uncinariasis. 
Double-current  irrigation  of  intestines, 
432 

lavage  tubes,  153 

needle  douche  for  sigmoid,  439 

rectal  irrigators,  432 

stomach  douche,  Gross',  156 
Douche,  fan,  170 

needle,  intestinal,  439 

Scotch,  170 

stomach,     155.     See    also    Stomach 
douche. 
Douglas'  pouch,  32 
Dripping  sounds  of  stomach,  81 
Drop  method  of  injecting  saline  solu- 
tion   into    rectum,    437.     See    also 

Proctoclysis. 
Drunkard's  catarrh,  190 
Dry  heat,  169 
Dulness,  hepatic,  59 
limits  of,  59 

splenic,  63 
Dunham's  thread  test  of  gastric  con- 
tents, 109 


Duodenal    bucket    for    obtaining    in- 
testinal juice,  420 
juice  in  fasting  stomach,  113 
ulcer,  543.     See     also     Ulcer,    duod- 
enal. 
Duodenitis,  acute,  482 
Duodenum,  anatomic  relations,  23 
anatomy,  22 
arterial  supply  of,  24 
ascending  portion,  23 
cancer  of,  565 
descending  part,  22 
divisions  of,  22 
Head's  zones  for,  612 
nerves  of,  24 

superior  horizontal  part,  22 
transverse  part  of,  23 
Dynamic  ileus,  645 
Dysentery,  501 
amebic,  503 

abscess  of  liver  in,  509 
acid  mixtures  in,  516 
acute,  510,  512 
antiseptics  in,  517 
diet  in,  516 
enemata  in,  518 
germicides  in,  517 
internal  medication  in,  516 
irrigation  in,  517 
local  treatment,  517 
medication  in,  515,  516 
rectal  injections  in,  517 
stools  in,  512 
treatment,  515,  516 
internal,  516 
local,  517 
blood  in,  513 
chronic,  510,  513 

appendicostomy  in,  520 
atrophic  enteritis  in,  508 
cecostomy  in,  520 

Gant's  modification,  520 
diet  in,  519 
fluorescein  in,  519 
medication  in,  519 
Rontgen  rays  in,  519 
treatment,  519 
medical,  519 
surgical,  520 
circulatory  system  in,  513 
classic  ulcers  in,  506 
classification,  510 


726 


INDEX 


Dysentery,  amebic,  cyst  formation  in, 

509 

definition,  503 

diagnosis,  514 

geographic  distribution,  503 

Harris  type,  505 

healing  process  in,  507 

hemorrhage    in,    treatment,    519, 
520 

history,  503 

hypertrophy  with  mucoid  degener- 
ation and  cyst  formation  in,  509 

in  aged,  513 

in  children,  513 

intestines  in,  505 

latent  infection,  511 

lesions  in,  location  of,  505,  508 

liver  abscess  in,  509 

masked  type,  511 

microscopic  pathology,  509 

mild  cases,  511 

moderately  severe  cases,  512 

mucoid  degeneration  in,  509 

omentum  in,  507 

pains  in,'  512,  514 

pathology,  505 

pre-ulceration  stage,  505 

prognosis,  515 

prophylaxis,  515 

Rogers'  small  red  dots  in,  505 

severe  cases,  512 

source  of  infection,  503 

subacute,  512 

symptoms,  510 

tenesmus  in,  512,  514 

carbonic  acid  gas  for,  519 

treatment,  515 

types  of,  505 

ulceration  in,  505 

undermined  ulcers  in,  506 
bacillary,  503,  520 

abscess  of  liver  in,  524 

acute,  treatment,  526 

bacillus  dysenteriae  as  cause,  521 

chronic,  treatment,  526 

clinical  types,  523 

complications,  524 

definition,  520 

diet  in,  527 

enemata  in,  526 

etiology,  520 

in  infants,  523 


Dysentery,    bacillary,    internal    treat- 
ment, 524 

irrigation  in,  526 

liver  abscess  in,  524 

local  treatment,  526 

medication  in,  524 

morbid  anatomy,  522 

prognosis,  524 

prophylaxis,  524 

serum  therapy  in,  527 

symptoms,  522 

tenesmus  in,  treatment,  525 

toxemia  in,  522 

treatment,  524 
classification,  503 
definition,  501 
diphtheritic,  501,  503,  523 
etiology,  501 

geographic  distribution,  502 
historic  note,  501 
in  war,  502 

predisposing  factors,  502 
sanitation  and,  502 
Dyspepsia,  amylaceous,  treatment,  445 
chronic,     189.     See     also     Gastritis, 

chronic. 
fatty,  treatment,  445 
fermentative,  diagnosis,  426 
gastric,  acute,  180.     See  also  Gastri- 
tis, simple  acute. 
intestinal,  444 

auto-intoxication  in,  444 

chronic  enteritis  and,   differentia- 
tion, 491 
nervous,  381 

course,  382 

diagnosis,  382 

diet  in,  139,  383 

differential  diagnosis,  382 

etiology,  381 

gastric  cancer  and,  differentiation, 

383 
juice  in,  381 

ulcer  and,  differentiation,  383 

gastritis  and,  differentiation,  383 

symptoms,  38 2 

treatment,  383 

pretubercular,  388 

Dyspeptic  asthma,  385 

auto-intoxication  in,  385 
diarrhea,  473,  476 
Dysphagia  in  cancer  of  cardia,  249 


INDEX 


727 


ECHINOCOCCI,  690 

Ectasia.     See  Ectasy. 
Ectasy,  diet  in,  139 

gastrosuccorrhea   continua   chronica 

and,  differentiation,  298 
of  stomach,  acute,  306 

age  and,  310 

anatomic  types,  307 

auto-intoxication  in,  308,  309 

cardiac  symptoms  with,  312 

clinical  types,  310 

constipation  in,  313,  314 
treatment,  319 

coprostasis  in,  314 

diagnosis,  71,  317 

diet  in,  318 

duodenum  in,  317 

duration  of  attack,  316 

etiology,  309 

from  auto-intoxication,  311 

from  convulsions,  311 

in  epilepsy,  310,  311 

in  infectious  diseases,  312 

in  migraine,  310,  311 

in  pneumonia,  313 

in  tetany,  31 1 

in  typhoid  fever,  312 

lavage  in,  318 

mechanism  of,  307 

microscopic  examination,  317 

morbid  anatomy,  316 

nutritive  enemata  in,  318 

of  nervous  origin,  311 

onset,  315 

operations  for,  319 

pain  in,  315 

percussion  in,  316 

peristalsis  in,  316 

physical  signs,  315 

postnarcotic  vomiting  in,  317 

postural  treatment,  319 

prognosis,  316 

prophylaxis,  318 

pseudo-angina     pectoris     with, 
312 

pulse  in,  309 

rectal  irrigation  in,  318,  319 

respiration  in,  309 

sex  and,  310 

splashing  sounds  in,  316 

stenotic,  71 

succussion  sounds  in,  316 


Ectasy  of  stomach,  acute,  supervening 
on  chronic  ectasy,  314 

surgical  treatment,  319 

symptoms,  309,  314 

tachycardia  with,  311,  312 

tenderness  in,  3 1 5 

theories  of,  307 

treatment,  318 

vomitus  in,  315 
atonic,  71,  321,  322 

adhesive  plaster  belt  in,  331,  332 

chronic,     auto-intoxication     in, 
322,  323 

constipation  in,  treatment,  334 

course,  324 

diagnosis,  326 

diet  in,  329 

differential  diagnosis,  328 

electricity  in,  333 

etiology,  322 

fermentation  in,  treatment,  334 

gastric  analysis  in,  324,  329 
tetany  in,  treatment,  335 

gastrosuccorrhea  in,  treatment, 

334 
hydrotherapy  in,  331 
in  epilepsy,  322,  323 
in  insane,  323 
in  melancholies,  322 
lavage  in,  332 
local  treatment,  332 
massage  in,  333 
mechanical  support,  331 
medication  in,  333 
nervous  conditions  and,  323 
operations  in,  335 
Rose's  adhesive  plaster  belt  in, 

331,  332 
stomach  douche  in,  ^t,t, 

spray  in,  333 
surgical  treatment,  335 
symptoms,  323 
tetany  in,  336 
thirst  in,  331 
treatment,  329 

local,  332 

surgical,  335 
chronic,  320 

acute    ectasy    supervening    on, 

314 
auscultatory  percussion  in,  327 
complications,  336 


728 


INDEX 


Ectasy   of  stomach,   chronic,   convul- 
sions in,  338 

definition,  320 

diagnosis,  71,  326 

differential  diagnosis,  321,  328 

epilepsy  in,  338 

Ewald's  test  breakfast  in,  327 

gastrodiaphany  in,  327 

gastroptosis     and,      differentia- 
tion, 320,  326 

inflation  in,  327 

inspection  in,  327 

kidney  in,  diagnosis,  326 

Leube's  test  meal  in,  328 

motor  functions  in,  327 

palpation  in,  327 

percussion  in,  327 

Rontgen  rays  in,  327 

scratch  method  in,  327 

test  breakfast  in,  327 
meal  in,  327,  328 

tetany  in,  336.     See  also  Tetany 
in  ectasy  of  stomach. 

transillumination  in,  327 

treatment,  329 
definition,  321 
diagnosis,  71,  316,  317 
in  gastric  cancer,  treatment,  274 
in  typhoid  fever,   postural  treat- 
ment, 539 
obstructive,    322,    325.     See    also 

Ectasy  of  stomach,  stenotic. 
stenotic,  71,  322,  325 

benign,  326 

diagnosis,  326 

diet  in,  335 

differential  diagnosis,  328 

etiology,  325 

gastric  analysis  in,  326,  329 

gastrosuccorrhea  in,  treatment, 
336 

lavage  in,  335 

malignant,  326 
treatment,  336 

operations  for,  336 

pathology,  325 

special  type,  326 

surgical  treatment,  336 

symptoms,  325 

tetany  in,  treatment,  336 

thirst  in,  treatment,  336 

treatment,  335 


Ectasy  of  stomach,  stenotic,  treatment, 
surgical,  336 
vomiting  in,  335 
Eczema,  auto-intoxication  in,  391 

stomach  functions  in,  391 
Edebohls'    palpation    in    appendicitis, 

607,  608 
Edema  in  gastric  cancer,  249 
Edinger  and  Spallanzani's  test  of  un- 

aspirated  gastric  contents,  108 
Egg-albumen  diet  in  gastric  ulcer,  229 
Egyptian     chlorosis,     701.     See     also 

Uncinariasis. 
Ehrlich's    diazo-reaction    in    typhoid 

fever,  533 
Einhorn's    bead    test      for    intestinal 
motor   functions,  420 
benzidin  test  paper,  1 14 
deglutible  electrode,  162 
divisible  esophageal  bougie,  250 
duodenal    bucket   for   obtaining   in- 
testinal juice,  420 
esophagoscope,  82 
gastric  spray,  158,  159 
gastrodiaphane,  83 
gastrograph  for  testing  motor  power, 

123 
instrument    for    spraying    stomach 

with  powders,  159,  160 
meat  powder,  209 
methods  of  localizing  gastric  ulcers, 

223 
radiodiaphane,  88 
radium  receptacle  for  treatment  of 

gastric  cancer,  266 
stomach  bucket,  109 

douche  instrument,  156 
stool  sieve,  415 

technic   of   intestinal   transillumina- 
tion, 404 
test  for  intestinal  juice,  113 
treatment  of  gastric  ulcer,  228 
Eisendrath's    classification    of    diver- 
ticulitis, 630 
Elastic  belts,  silk,  179 
Electric     irrigation     in     constipation, 
Kemp's,  468 
roller     massage,     hot-and-cold,     in 
constipation,  467 
Electricity  in  atonic  ectasy  of  stomach, 

333 
in  chronic  gastric  atony,  306 


INDEX 


729 


Electricity  in  chronic  gastritis,  197 
in  constipation,  468 
in  gastroptosis,  357 
in  hyperchlorhydria,  291 
in  intestinal  diseases,  440 
in  stomach  diseases,  161 
indications,  164 
intragastric  method,  161 
percutaneous  method,  161 
intrarectal,  441 
static,  164 
Electrodes,  Bassler's,  163 
deglutible,  Einhorn's,  162 
Lockwood's,  i6t,  162 
Electro-enteroclysis,     electric     attach- 
ment for,  431 
Elsberg's  division  of  Head's  zones,  611 
Elsberg  and  Neuhof's  method  of  diag- 
nosis by  Head's  zones,  610 
Emaciation  in  gastric  cancer,  246 
Enabolic  intestinal  ulcers,  547 
symptoms,  551 
treatment,  553 
Embolism  of  inferior  mesenteric  artery, 

557 
of  mesenteric  arteries,  554 
clinical  symptoms,  556 
diagnosis,  557 
etiology,  555 
prognosis,  557 
treatment,  558 
veins,  554 

treatment,  558 
of  superior  mesenteric  artery,  555 
Ems'  salt  for  balantidia,  685 
Endo-appendicitis,  594,  595 

symptoms,  597 
Enemata,  428,  429 

high,  with  colon-tube,  429 
in  acute  amebic  dysentery,  518 
in  bacillary  dysentery,  526 
in  constipation,  468 
nutritive,  in  acute  gastric  ectasy,  318 
in  gastric  ulcer,  227,  228 
rectal,  137 
saline,  137 
uses,  428 
value  of,  436 
Enteralgia,  453 
clinical  value,  454 
diagnosis,  454 
etiology,  453 


Enteralgia,  gastralgia  and,  differentia- 
tion, 368 

in  cancer,  566 

nervous,  670 

prognosis,  454 

symptoms,  454 

treatment,  454 
Enteritis,  478 

acute,  478 
age  and,  478 

auto-intoxication  in,  478,  482 
bile-pigment  and,  484 
calomel  in,  484,  485 
diagnosis  of,  to  localize  lesion,  482, 

483 
diet  in,  486 
duration,  484 
enteroclysis  in,  485,  486 
etiology,  478 
feces  in,  480,  481 

examination  of,   to  localize   le- 
sion, 483 
fever  in,  482 
hydrotherapy  in,  486 
idiopathic,  478 
irrigations  in,  486 
laxatives  in,  484 
localization,  482 
medication  in,  484,  485 
microscopic  anatomy,  480 
morbid  anatomy,  479 
opiates  in,  485,  486 
physical  signs,  481 

localization,  482 
prescriptions  in,  485 
primary,  478 
prognosis,  484 
prophylaxis,  484 
secondary,  479 
symptoms,  480 

subjective,  481 
treatment,  484 
urine,  482 
chronic,  487 

atrophic,  in  amebic  dysentery,  508 

atrophy  of  mucosa  in,  48S 

auto-intoxication  in,  490 

bowel  movements  in,  490,  491 

catarrhal,  490 

chronic  catarrhal  colitis  in,  490 

constipation  in,  490 

diet  in,  495 


730 


INDEX 


Enteritis,     chronic,    constipation     in, 
treatment,  496 

course,  493 

diarrhea  in,  490,  491 

diet  in,  495 

differential  diagnosis,  493 

enemata  in,  497 

etiology,  487 

feces  in,  489 

hydrotherapy  in,  494,  496 

hygienic  treatment,  494       ^ 

hypertrophy  in,  488 

idiopathic,  487 

intestinal    dyspepsia    and,    differ- 
entiation, 491 

local  treatment,  497 

massage  in,  495 

medication  in,  496 

morbid  anatomy,  487 

mucus  in  feces  in,  487,  490,  491 

nervous  factor  in,  49 1 

peristalsis  in,  490,  491 

physical  signs,  490 

primary,  487 

prognosis,  494 

rectal  examination  in,  487,  493 

sago  grains  in,  489 

secondary,  487 

surgical  treatment,  498 

symptoms,  489 

treatment,  494 

ulceration  in,  489 

urinary  findings  in,  495 
follicularis  seu  nodularis,  480 
membranacea,  491 
membranous,  672.     See    also    Colic, 

tnucous. 
mucus  in  feces  as  sign,  410,  411 
of  large  intestine,  diagnosis,  483 
of  small  intestine,  diagnosis,  483,  484 
of  upper  colon,  diagnosis,  483 
phlegmonous,  500 
purulent,  500 
Enteroclysis,  429  * 

double-current,  432 
in  acute  enteritis,  486 
in  ascaris  lumbricoides,  699 
in  constipation,  468 
in  mucous  colic,  676,  677 
position  for,  432-435 
value  of,  436 
•without  bed-pan,  434 


Enterocolitis,    chronic,   487.     See   also 

Enteritis,  chronic. 
Enterofaradization,  163,  164 
Enterogastroptosis,  348,  349 
Enterogenic  cyanosis,  450 

auto-intoxication  in,  450 
Enterokinase,  38 

Enteroliths,  differential  diagnosis,  651 
in  feces,  416 
occlusion  from,  645 
treatment,  655 
Enteroptosis,  341,  349,  456 

mucous  colic  and,  674 
Epilepsy,  acute  ectasy  of  stomach  in, 
310,  311 
atonic  ectasy  of  stomach  in,  322,  323 
auto-intoxication,  311,  322,  338 
in  ectasy  of  stomach,  338 
Epithelial  cells  in  gastric  contents,  119 
Epithelioma  of  stomach,  242 
Epithelium  in  feces,  419 
Erb's  sign  in  gastric  tetany,  337 
Erepsin,  38 

Erosions  of  stomach,  236 
acute,  236 
chronic,  237 

bismuth  treatment,  238 
diet  in,  238 
emaciation  in,  238 
etiology,  237 
gastric  analysis  in,  238 
nitrate  of  silver  treatment,  238 
pains  in,  238 
prognosis,  238 
suprarenal  extract  in,  239 
symptoms,  237 
treatment,  238 
weakness  in,  238 
hemorrhagic,  236 
Eructatio  nervosa,  375 
Eructation,  375 

Eruptions,    cutaneous,     auto-intoxica- 
tion in,  391 
from  foods,  364,  391 
Erysipelas  toxin  in  gastric  cancer,  274 
Erythema  from  foods,  364 

stomach  functions  in,  391 
Erythrodextrin,  test  for,  106 
Esculin   as  fluorescent  medium  in  gas- 

trodiaphany,  85 
Esophageal  bougie,  divisible,  250 
orifice  of  stomach,  17 


INDEX 


731 


Esophagoscope,  46 
Einhorn's,  82 

Esophagoscopy,  82 

Esophagus,  auscultation  of,  46 
examination  of,  46 

in  cancer  of  cardia,  250 
instrumental,  46 
obstruction  of,  47 
palpation  of,  46 
stricture  of,  47 

in  cancer  of  cardia,  250 

Etat  mamelonne  in  chronic  catarrhal 
gastritis,  191 

Eventration  treatment  of  gastric  can- 
cer, 275 

Ewald's  aspirating  tube,  91 
nutritive  rectal  enema,  137 
test  meal,  90 

Ewald  and  Boas'  method  of  expressing 
gastric  contents,  93 
test  breakfast,  90 
and  Siever's  test  for  motor  power, 
122 

Ewald-Rosenheim      stomach     douche- 
tube,  156 

Examination,  physical,  general   meth- 
ods, 45 

Examining  rectal  speculum,  398 

Exercise  in  intestinal  diseases,  439 

Expiration  fixation  of  tumor  in  gastric 
cancer,  248 

Exposed  hepatic  dulness,  upper  limit  of, 

59 
Expression  of  gastric  contents,  Ewald- 
Boas  method,  93 
Kemp's  method,  94 
Exulceratio  simplex,  235 

Faber  and  Penzoldt's  test  of  absorp- 
tive function  of  stomach,   121 
False  diverticula,  624 
Fan  douche,  170 
Faradism  to  intestines,  163,  164 

to  stomach,  163,  164 
Fasting  stomach,  bile  in,  113 
contents  of,  112 
duodenal  juice  in,  113 
intestinal  juice  in,  113 
pancreatic  juice  in,  113 
Fat,  absorption  of,  40 
in  feces,  412,  417 
milk,  Gartner's,  136 


Fat,  subcutaneous  injection  of,  137 
Fatty  acids  in  gastric  contents,  102 

dyspepsia,  treatment,  445 
Febrile  diseases,  acute,  stomach  func- 
tions in,  387 
chronic,  stomach  functions  in,  388 
Fecal  colic,  463 
treatment,  471 
fever,  464 
tumors,  463 
treatment,  471 
Feces,  accumulation  of,  in  appendici- 
tis, 617 
obstruction  by,  661 

auto-intoxication  in,  661 
differential  diagnosis,  651 
treatment,  653 
acholic,  414 
administration  of  special   substance 

to  mark,  421 
albumin  in,  411,  412 
bacillus  aerogenes  capsulatus  in,  420 
coli  in,  420 

lactis  aerogenes  in,  420 
bacteria  in,  419 
bacteriologic   examination   of,    from 

test  diet,  424 
bile-pigment  in,  413,  416 
sublimate  test  for,  425 
biliary  acids  in,  413 

calculi  in,  416 
blood  in,  410,  413,  419 
test  for,  1 14 
in  intestinal  cancer,  567 
ulcers,  552 
calculi  in,  416 
cancer  fragments  in,  410 
carbohydrates  in,  412 

fermentation  test  for,  425 
Charcot-Leyden  crystals  in,  418 
chemic  examination  of,  411 

from  test  diet,  425 
cholesterin  in,  416 
collection  of,  422 
colorless,  414 
concretions  in,  415,  416 
connective-tissue  fibers,  410 
coproliths  in,  416 
crystals  in,  418 
diastase  in,  415 
enteroliths  in,  416 
epithelium  in,  419 


732 


INDEX 


Feces,  examination  of,  409 

bacteriologic,  from  test  diet,  424 

chemic,  411 

from  test  diet,  425 

from  test  diet,  423-428 
results,  427 

macroscopic,  409 
after  test  diet,  423 

microscopic,  409,  416 
after  test  diet,  424 

to  localize  enteritis,  483 
fat  in,  412,  417 
fatty,  414 

fermentation  test  for,  425 
ferments  in,  415 
food  remnants  in,  409 
foreign  bodies  in,  415,  416 
frogs'  spawn  bodies  in,  410 
gall-stones  in,  416 
general  view  of,  417 
in  acute  amebic  dysentery,  512 

enteritis,  480,  481 
in  chronic  enteritis,  489 
in  intestinal  cancer,  563,  567 

ulcer,  552. 
indol  in,  tests  for,  426 
macroscopic  examination  of,  409 

after  test  diet,  423 
marking    of,    by    administration    of 

special  substance,  421 
meat -fibers  in,  418 
micro-organisms  in,  419 
microscopic  examination  of,  416 

after  test  diet,  424 
mucin  in,  410 

test  for,  411 
mucus  in,  410,  419 

in  chronic  enteritis,  487,  490,  491 

in  intestinal  ulcer,  553 
odor  of,  409 

colon  bacilli  and,  39 
pancreatic  calculi  in,  416 
parasites  in,  411 
peptone  in,  412 
polypi  fragments  in,  410 
propeptone  in,  412 
proteid  in  fermentation  test  for,  425 
pus  in,  410,  419 

in  intestinal  cancer,  567 
ulcer,  552 
putrefactive  products  in,   tests  for, 

426 


Feces,  quantity  of,  39,  409 

reaction  of,  39,  411 
from  test  diet,  425 

red  blood  corpuscles  in,  419 

sago  grains  in,  410 

sand  in,  416 

sieve  for,  Einhorn's,  415 

skatol  in,  tests  for,  426 

starch  in,  410 

examination  for,  412 

sugar  in,  412 

test-diet,  bacteriologic  examination, 
424 
characteristics  of,  423 
chemic  examination  of,  425 
examination  of,  results,  427 
macroscopic  examination,  423 
microscopic  examination,  424 
reaction  of,  425 

tissue  shreds  in,  in  intestinal  ulcers, 

553 

transportation  of,  422 

trypsin  in,  415 

tubercle  bacilli  in,  in  intestinal  tuber- 
culosis, 553 

tumor  fragments  in,  410,  419 

urobilin  in,  413 

vomiting  of,  in  intussusception,  644 

worms  in,  415 
Feeding  to  spare  stomach,  136 
Fermentation,  gastric  development  of, 
118 

in  stomach,  gas,  no 

test  for  feces,  425 

tube,  Strasburger's,  426 
Ferments  in  feces,  415 

milk-curdling,  cells  secreting,  20 

of  digestion,  34 

of  gastric  juice,  35 

of  intestine,  organized,  38 

of  saliva,  34 
Fever,  auto-intoxication  in,  323 
Fibrin  increase  in  appendicitis,  605 
Fibrolysin  in  gastric  cancer,  267 
Fibroma  of  intestines,  572 

of  stomach,  275 
Fibrous  carcinoma  of  stomach,  242 
Fibromyoma  of  intestines,  572 
Figs,  syrup  of,  in  constipation,  470 
Filicic  acid  for  tapeworms,  691 
Filmaron  for  tapeworms,  691 
Finger-breadth,  48 


INDEX 


733 


Fish,  chemic  composition  of,  130 

Fissure  of  anus,  588 

Fistulae  in  diverticulitis,  vesicocolic,  633 

submucous,  in  diverticulitis,  631 
Flatulence,  diverticula  and,  627 
Flatus  in  proctoclysis,  43S 
Fleischer's  test  for  urobilin  in  feces,  414 
Flicking  percussion,  52,  53 
Floating  kidney.     See  Nephroptosis. 

liver,  352 

spleen,  64 
Flexner-Harris  type  of  bacillus  dysen- 

terise,  521 
Fluke  worms,  692 
blood,  693 
liver,  692 
Fluorescein  and  resorcin  as  medium  in 
gastrodiaphany,  85 

in  chronic  amebic  dysentery,  519 

in  treatment  of  gastric  cancer,  265 
Fluorescent  media  in  gastrodiaphany, 

85 
Food,  albumin  in,  replacing  of,  135 
animal,  127 

and  vegetable,  difference,  127 
caloric  value  of,  126,  127,   128 

calculating,  124,  132 
chemic  composition  of,  130 
constipating,  443 
digestibility  of,  134 
Leube's  scale,  135 
Penzoldt's  scale,  135 
gelatinous,  136 
in  hot  weather,  1 30 
laxative,  442 
remnants  in  feces,  409 
requirement,  124,  125 
solid,  pastry,  and  broths  with   milk 

diet,  133 
vegetable,  127 
Foreign  bodies,  diverticulitis  and,  632 
in  feces,  415,  416 
in  stomach,  277 

Rontgen  rays  for  detecting,  87 
Fore-stomach,  340 
Free  hydrochloric  acid,   96.     See  also 

Hydrochloric  acid,  free. 
Friedlieb's  lavage  apparatus,  146,  148 

modified,  149 
Frogs'  spawn  bodies  in  feces,  410 
Fruits,  chemic  composition  of,  132 
food  value  of,  1 29 


Fuld's  test  for  pepsin,  104 

Fuming  nitric  acid  for  cauterizing  hem- 
orrhoids, 585 

Functional  diseases  of  stomach,  279 

Functions  of  stomach,  examination  of, 
90 

Fundus  glands,  17,  20 

Fungi  in  gastric  contents,  120 

Funnel  for  lavage,  140,  144 
method  of  lavage,  140 

Furunculosis,  auto-intoxication  in,  391 

GaIvActose,  absorption  of,  40 
Gallant  corset,  354,  355 

supporting,  179 
Gall-bladder  adhesions,  spider,  gastric 
ulcer  and,  differentiation,  223 
anatomic  relations  of,  57 
cancer  of,  gastric  cancer  and,  differ- 
entiation, 259 
distended,  differentiation  from  mov- 
able right  kidney,  70 
Head's  zone  for,  613 
in  typhoid  fever,  530 
inspection  of,  57 
palpation  of,  58 
percussion  of,  59 
physical  examination  of,  57 
Gall-stones,  gastralgia  and,  differentia- 
tion, 368 
in  feces,  416 

intestinal  obstruction  Isy,  644 
differential  diagnosis,  650 
treatment,  655 
Galvanization  in  gastrosuccorrhea  con- 
,tinua  chronica,  302 
to  stomach,  163,  164 
Game,  chemic  composition  of,  130 
Gant's     examining     rectal     speculum, 
398 
hinged  rectal  speculum,  399 
modified  cecostomy  in  amebic  dysen- 
tery, 520 
water  infiltration  method  for  hemor- 
rhoids, 586 
Gartner's  fat  milk,  136 
Gas  cysts  of  intestines,  573 
fermentation  in  stomach,  no 

significance,  110,  in 
in  intestines,     abnormal,     45 1 .     See 
also  Tympanites. 
Gastralgia,  365 


734 


INDEX 


Gastralgia,  achylia  gastrica  and,  differ- 
entiation, 367 

as  neurosis,  366 

chronic  gastritis  and,  differentiation, 
367 

differential  diagnosis,  367 

duration,  367 

enteralgia  and,  differentiation,  368 

etiology,  366 

forms  of,  366 

from  cerebral  disease,  366 

from  foods,  366 

from  myelitis,  366 

from  spinal  disease,  366 

from  tabes,  366 

gall-stones  and,  differentiation,  368 

gastric   cancer   and,    differentiation, 

367 

hyperchlorhydria  and,  differentia- 
tion, 367 

hypersecretion    and,    differentiation, 

367 
intercostal    neuralgia   and,    differen- 
tiation, 368 
intestinal   colic  and,   differentiation, 

368 
myalgia  and,  differentiation,  368 
nervous,   gastric  cancer  and,   differ- 
entiation, 259 
ulcer  and,    differentiation,    221, 
222 
hyperchlorhydria  and,  differentia- 
tion, 285 
originating  in  stomach,  366 
perigastritis  and,  differentiation,  368 
prognosis,  367 
pyloric  stenosis  and,  differentiation, 

367 
reflex  causes,  366 

renal  calculi  and,  differentiation,  368 
rheumatism  and,  differentiation,  368 
sex  in,  366 
symptoms,  366 
treatment,  368 
ulcer  of  stomach  and,  differentiation, 

367 
Gastralgokenosis,  369 
Gastrectasy,   320.     See  also  Ecfasy  of 

stomach,  chronic. 
Gastrectomy,  partial,  for  pyloric  cancer, 

263 
Gastric  catarrh.     See  Gastritis. 


Gastric   contents,   abnormal    constitu- 
ents,  113 

acetic  acid  in,  103 

achroodextrin  in,  106 

acid  salts  in,  99,  100 

amebae  in,  117 

amylopsin  in,  113 

aspiration  of,  91.     See  also  Aspi- 
ration  of  gastric  contents. 

bile  in,  113 

blood  in,  113.     See  also  Blood. 

Boas-Oppler  bacillus  in,  117,  119 

carbon  dioxid  in,  no 

chymosinogen  in,  105 

dextrin  in,  106 

Dunham's  thread  test,  109 

Edinger    and    Spallanzani's    test, 
without  aspiration,  108 

Einhorn's     stomach -bucket     test, 
109 

epithelial  cells  in,  119 

erythrodextrin  in,  106 

examination  of,  95 
chemic,  95 
macroscopic,  96 
microscopic,  116,  117 
tests,  96 

expression  of,  93 

fasting,  112 

fatty  acids  in,  102 

fermentation  in,  no 

fungi  in,  120 

gases  in,  no 

gastric  mucosa  in,  119 

Gunzburg's  test  of,  without   aspi- 
ration, 108 

hydrochloric  acid  in,  96.     See  also 
Hydrochloric  acid. 

in  achylia  gastrica,  206 

in  atonic  ectasy,  324,  329 

in  chronic  gastric  atony,  305 
erosions,  238 
gastritis,  193 
intestinal  obstruction,  659 

in  duodenal  ulcer,  545 

in  gastric  cancer,  251 

in  gastroptosis,  348 

in       gastrosuccorrhea        continua 
chronica,  298 
periodica,  294 

in  hyperchlorhydria,  282 

in  stenotic  ectasy,  326,  329 


INDEX 


735 


Gastric  contents  in  ulcer  of  stomach,  218 
infusoria  in,  117 
intestinal  juice  in,  113 
lactic  acid  in,  100.     See  also  Lactic 

acid. 
maltose  in,  106 
megastoma  entericum  in,  117 
micro-organisms  in,  118 
mould  in,  118,  120 
mucus  in,  113,  116 
o'idium  albicans  in,  1 20 
penicillium  glaucum  in,  120 
pepsin  in,  103.     See  also  Pepsin. 
peptone  in,  103 
propeptone  in,  103 
pus  in,  115 
quantity  of,  95 

motor  function  and,  95 
reaction,  97 

rennet  in,  105.     See  also  Rennet. 
saccharin  in,  106 
Sahli's  desmoid  test  for,  108 
sarcinae  in,  117,  119 
Spallanzani    and    Edinger's    test, 

without    aspiration,  108 
starch    digestion    and,     106.     See 
also  Starch  digestion. 

granules  in,  118 
steapsin  in,  113 
.  succinic  acid  in,  121 
sugar  in,  106 

thread  test,  Dunham's,  109 
total  acidity,  Topfer's  method  for, 

99 
trichomonas  hominis  in,  117 
trypsin  in,  113 
tumor  particles  in,  119 
volatile  acids  in,  102 
yeast-cells  in,  118,  119 
dyspepsia,     acute,      180.     See     also 

Gastritis,  simple  acute. 
fermentation,  development,  118 
juice,  35 

continuous  secretion  of,  291.     See 

also  Gastrosuccorrhea. 
hydrochloric  acid  in,  35,  96.     See 

also  Hydrochloric  acid. 
in  nervous  dyspepsia,  381 
normal,  96 
pepsin  in,  35 
testing  of,  95,  108,  116.      See  also 

Gastric  contents. 


Gastric    mucosa    in    gastric    contents, 

119 
stamper  method  of  localizing  ulcer, 

223 
Gastritis,  acid,  190,  194 

hyperchlorhydria  and,  differentia- 
tion, 285 

treatment,  195 
acute,  180 

auto-intoxication  in,  181 

diet  in,  138 
atrophic,    191,    194,    203.     See   also 

Achylia  gastrica. 
catarrhal,  chronic,  190,  191 
chronic,  189 

absorption  in,  194 

achylia  gastrica   and,  differentia- 
tion, 195 

alkaline-saline  waters  in,  199 

auto-intoxication  in,  193 

belching  in,  treatment,  201 

cancer  and,   differentiation,    195, 

259 

Carlsbad  salts  in,  199 

catarrhal,  190,  191 

classification,  190 

constipation  in,  treatment,  201 

course,  194 

diagnosis,  193 
differential,  194 

diet  in,  139,  197 

electricity  in,  197 

etiology,  189 

gas  in,  treatment,  201 

gastralgia  and,  differentiation,  367 

gastric  contents  in,  193 

hydrotherapy  in,  197 

hygienic  treatment,  196 

inspection  in,  193 

intestinal   fermentation   in,    treat- 
ment, 201 

lavage  in,  ig6 

massage  in,  197 

medication  in,  200 

microscopic  examination  in,  194 

mineral  waters  in,  199 

morbid  anatomy,  191 

motor  function  in,  194 

nausea  in,  treatment,  201 

nervous   dyspepsia   and,    differen- 
tiation, 383 
symptoms,  treatment,  201 


736 


INDEX 


Gastritis,   chronic,   neuroses  and,  dif- 
ferentiation, 195 
palpation  in,  193 
percussion  in,  193 
physical  examination,  193 
prognosis,  195 
prophylaxis,  195 
removal  of  mucus  in,  196 
saline  waters  in,  199 
smoking  in,  199 
splashing  sound  in,  193 
stomachics  in,  200 
symptoms,  192 
test-breakfast  in,  193 
treatment,  195 
dietetic,  197 
electric,  197 
hydro  therapeutic,  197 
hygienic,  196 
local,  196 
medical,  200 
of  belching,  201 
of  constipation,  201 
of  gas,  201 

of  intestinal  fermentation,  201 
of  nausea,  201 
of  vomiting,  201 
ulcer  and,  differentiation,  194 
urine  in,  193 

vibratory  massage  in,  197 
vomiting  in,  treatment,  201 
diphtheric,  181 
hyperpeptica,  190 
hypersthenic,  190 
membranous,  181 
mucous,  194 
phlegmonosa,  188 
phlegmonous,  188 

blood  examination  in,  189 
circumscribed  type,  188,  189 
diagnosis,  189 
diffuse  type,  188 
duration,  189 
morbid  anatomy,  188 
symptoms,  188 
treatment,  189 
polyposa,  190 
simple  acute,  180 
diagnosis,  182 
diet  in,  184 
duration,  182 
etiology,  180 


Gastritis,  simple  acute,  heat  in,  treat- 
ment, 183 
microscopic  anatomy,  181 
morbid  anatomy,  181 
nausea  in,  treatment,  183,  184 
physical  examination,  182 
predisposition,  180 
prognosis,  182 
prophylaxis,  182 
symptoms,  181 
treatment,  182 
of  mild  cases,  183 
of  severe  cases,  184 
urine  in,  182 

vomiting  in,  treatment,  183,  184 
toxic,  185 

after-treatment,  188 
anatomy,  185 
antidotes,  187 
demulcents,  187 
diagnosis,  186 
etiology,  185 
prognosis,  186 
symptoms,  185 
treatment,  186 
Gastrodiaphane,  83 
circumscribing,  83,  84 
Einhorn's,  83 
Gastrodiaphany,  83 

conclusions  regarding,  89 
fluorescent  media  in,  85 
radium,  188 
technic,  86 
Gastrodynia,    365.     See    also    Gastral- 

gia. 
Gastro-enteroptosis,  348,  349 
Gastro-enterostomy  for  gastric  cancer, 

264 
Gastrofaradization,  163,  164 
Gastrogalvanization,  163,  164 
Gastrograph  for  testing  motor  power, 

123 
Gastroptosia,    341.     See   also  Gastrop- 

tosis. 
Gastroptosis,  71,  341 

abdominal  support  in,  354 

age  and,  346 

anatomic  considerations,  342 

auto-intoxication  in,  345 

chronic  ectasy  and,   differentiation, 

320,  326 
complicating  hyperchlorhydria,  284 


INDEX 


737 


Gastroptosis,  complications,  treatment, 
358 

constipation  in,  treatment,  358 

corsets  in,  355 

crescentic,  349,  350 

definition,  341 

degrees  of,  348 

diagnosis,  71,  73,  353 
kidney  in,  342 

diet  in,  139 

to    increase    abdominal    pressure, 
356 

Dietl's  crisis  in,  treatment,  358 

electricity  in,  357 

elevation  of  foot  of  bed  in,  357 

etiology,  345 

exercise  in,  356 

gastric  analysis  in,  348 

gastrodiaphany  in,  348 

Glenard's  belt  test  in,  353 

gymnastics  in,  356 

hydrotherapy  in,  358 

increase    of   abdominal    pressure  in, 
treatment,  356 

inflation  in,  348 

inspection  in,  347 

massage  in,  356 

medication  in,  357 

motor  functions  in,  348 

nephropexy  in,  346 

operations  for,  358 

palpation  in,  347 

percussion  in,  348 

physical  examination,  347 

prognosis,  353 

prophylaxis,  353 

Russell's  diet  treatment,  356 

scratch  pitch  in,  77 

sex  and,  346 

splashing  sounds  in,  347 

surgical  treatment,  358 

symptoms,  346 

treatment,  353,  354 
surgical,  358 
Gastroscopy,  83 
Gastrospasmus,    365.     See    also    Gas- 

tralgia. 
Gastrostomy  for  cancer,  264 
Gastrosuccorrhea,  291 

continua  chronica,  296 
alkali  treatment,  301 
diagnosis,  296,  298 
47 


Gastrosuccorrhea    continua    chronica, 
diet  in,  300 

differential  diagnosis,  298 

ectasy  and,  differentiation,  298 

etiology,  297 

frequency,  297 

galvanization  in,  302 

gastric  analysis  in,  298 

ulcer  and,  differentiation,  298 

lavage  in,  301 

medication  in,  300 

pain  in,  treatment,  300 

prognosis,  299 

prophylaxis,  299 

stomach  spray  in,  301 

symptoms,  297 

tetany  and,  differentiation,  299 

treatment,  299 
periodica,  292 

diagnosis,  294 

diet  in,  296 

etiology,  293 

gastric  contents  in,  294 

history,  292 

hydrotherapy  in,  295 

lavage  in,  295 

nausea  in,  treatment,  295 

pain  in,  treatment,  295 

prognosis,  294 

prophylaxis,  294 

symptoms,  293 

thirst  in,  treatment,  295 

treatment,  294 

vomiting  in,  treatment,  295 

vomitus  in,  293 
diagnosis,  291,  292 
diet  in,  139 
examination  of  fasting  stomach  in, 

112 
gastralgia  and,  differentiation,  367 
hyperchlorhydria     and,     diflferentia- 

tion,  285 
in  atonic  atony,  treatment,  334 
in  stenotic  ectasy,  treatment,  336 
intermittent    form,     292.     See    also 
Gastrosuccorrhea  continua  periodica. 
Gastroxynsis,    291.     See    also    Gastro- 
succorrhea. 
Gavage,  153 

Gelatin  in  intestinal  diseases,  443 
in  typhoid  fever,  536 
treatment  of  gastric  ulcer,  231,  232 


738 


INDBX 


Gelatinous  foods,  136 
Germain  See's  test  meal,  90 
Germicides  in  acute  amebic  dysentery, 

517 
Gersuny's  adhesion  symptom  of  fecal 

tumor,  463 
Gibson's   differential   chart   for  leuko- 
cytosis, 605 
Girdle  ulcer,  549 
Glands  of  stomach,  20 
Glass  rectal  irrigator,  431 
Glenard's  belt  test  in  ptosis,  353 

disease,  341 
Glucose,  absorption  of,  40 
Glycerin  injections  in  constipation,  469 
to  intensify  fluorescence  in  gastro- 
diaphany,  85 
Glycosuria,  alimentary,  40 
Gonorrhea  of  intestines,  551 
symptoms,  551 
treatment,  553 
Gout,  stomach  functions  in,  391 
Greater  cul-de-sac  of  stomach,  17 
curvature  of  stomach,  18 
omentum,  19 
Gross'  double-current  stomach  douche, 
156 
test  for  pepsin,  104 
Ground  itch,  703 

Gtinzburg's  test  for  free  hydrochloric 
acid,  97 
of    unaspirated    gastric    contents, 
108 
Gurgling  sounds  in  intestines,  404 

of  stomach,  21 
Gymnastics  in  constipation,  467 

in  intestinal  diseases,  439 
Gyromele,  439 
Tiirck's,  164 

HabituaIv  constipation,  458.     See  also 

Constipation. 
Haggard,  137 

Hammer  percussion,  52,  53 
Hand-breadth,  48 
Haustra  coli  of  large  intestine,  29 
Harris'  type  of  amebic  dysentery,  505 
Harris-Flexner  type  of  bacillus  dysen- 

teria?,  521 
Head's  zones,  Elsberg's  division  of,  611 
Elsberg  and  Neuhof's  method  of 
diagnosing  by,  610 


Head's  zones  in  affections  of   appen- 
dix, 609,  614 
of  duodenum,  612 
of  gall-bladder,  613 
of  intestines,  615 
of  kidney,  614 
of  liver,  613 
of  lungs,  609 
of  stomach,  612 
of  ureter,  614 
of  uterine  adnexa,  615 
of  uterus,  6 1 5 
of  viscera,  609 
in  ileocecal  tuberculosis,  615 
in  perforation  of  ileum,  615 
in  visceral  affections,  609 
precautions,  610,  611 
objective,  611 
subjective,  612 
Heart  block,  transient,  auto-intoxica- 
tion in,  446 
lesions,  stomach  functions  in,  389 
ptosis  of,  353 
Heart-burn,  375 

Heat  in  simple  acute  gastritis,  183 
in  treatment  of  simple  acute  gastritis, 

183 
unit,  124 
Heat-retaining  proctoclysis  bottle,  437 
Heichelheim's   test   for   motor    power 

123 
Hematemesis.     See  Hemorrhage. 
Hematuria,  endemic,  693  ^ 
Hemic  distomiasis,  693 
Hemmeter-Moritz  test  for  motor  power, 

123 
Hemolymph  glands  in  uncinarial  der- 
matitis, 705 
Hemorrhage     in     amebic     dysentery, 
treatment,  519,  520 
in  duodenal  ulcers,  545 
in  gastric  cancer,  246 
treatment,  274 
ulcer,  217 

treatment,  224 
operative,  235 
in  hemorrhoids,  577,  578 

treatment,  583 
in  intestinal  ulcer,  552 
in  typhoid  fever,  death  from,  530 

treatment,  539 
intestinal,  542 


INDEX 


739 


Hemorrhage,  intestinal,  treatment,  553 

of  stomach,  211 
Hemorrhagic  erosions  of  stomach,  236 
Hemorrhoidal  plexus,  574 
Hemorrhoids,  574 
age  and,  576 

Allingham's  operation  for,  585 
anatomy,  574 
arterial,  575 
bowels  in,  579 
capillary,  575 

carbolic  acid  injections  for,  584 
cathartics  in,  579 
cauterization  of,  with  fuming  nitric 

acid,  585 
clamp  and  cautery  treatment,  585 
complications,  586 
condom  as  cooler  in,  581 
condyloma  in,  578 
constipation  and,  576 

treatment,  579 
crushing  of,  585 
definition,  574 
diagnosis,  577,  578 
diet  in,  579 

dilatation  of  sphincters  for,  584 
etiology,  575 
exercise  in,  579 
external,  574 

anatomy,  574 

diagnosis,  578 

diet  in,  579 

etiology,  575 

inflammation  in,  relief  of,  581,  582 

pain  in,  treatment,  581,  582 

prognosis,  578 

symptoms,  577 

treatment,  579,  580 
local,  580,  581 
extirpation  of,  585 

with  suture,  586 
fissure  in  ano  in,  588 
frequency,  576 

Gant's  water  infiltration  method,  586 
hemorrhage  in,  577,  578 

treatment,  5H3 
hygiene  in,  579 

of  anus  in,  580 
ice  tubes  for,  580,  58 1 
infiltration  treatment,  Gant's,  586 
internal,  574 

anatomy,  574 


Hemorrhoids,  internal,  diagnosis,  578 
diet  in,  579 
etiology,  575 
prognosis,  578 
symptoms,  577 
treatment,  579,  581 

local,  582 
varieties,  575 
Kemp's  ice  tube  for,  580 

soft-rubber  rectal  bag  in,  581 
tube  for,  580 
ligature  of,  585 

with  extirpation,  585 
ointments  for,  582,  583 
operations  for,  584 
proctitis  with,  590 
prognosis,  578 
prolapse  of  rectum  in,  586 
prolapsed,  treatment,  582 
rectal  cancer  and,  568 
secondary  changes,  575 
sex  and,  576 
suppositories  in,  583 
symptoms,  577 
tamponing  rectum  for  hemorrhage, 

583 
tenesmus  in,  577 
treatment,  579 
radical,  584 
ulcerated,  treatment,  582 
venous,  575 

water  infiltration  treatment,  586 
Whitehead's  operation,  586 
Hepatic  flexure  of  ascending  colon,  31 
irritation,  auto-intoxication  in,  446 
Hernia,  diaphragmatic,  638,  639 
from  strangulation,  internal,  636 

mechanism,  639 
internal,  strangulation  from,  638 
perforation  of  sac,  in  diverticulitis, 
632 
Hershell's  test  of  absorptive  function 

of  stomach,  121 
Heryng    and    Reichmann's    gastrodia- 

phane,  83 
Heterologous   blood    of   ])ig   in    gastric 

cancer,  274 
High-frequency  current,  164 
Hinged  rectal  speculum,  399 
Hirschsprung's  disease,  456 
Hiss-Russell    tyi)e   of   bacillus   dysen- 
teriae,  521 


740 


INDEX 


History  of  patient,  42 

Hoffmann's  sign  in  gastric  tetany,  337 

Hoist  and  Schlesinger's  test  for  blood  in 
gastric  contents,  114 

Honigmann's  determination  of  hydro- 
chloric acid  deficit,  107 

Hookworm  disease,  701.  See  also 
Uncinariasis. 

Hot  and  cold  alternate  stomach  douche, 

157 
applications,  dry,  169 

moist,  169 
weather,  food  in,  130 
Hot-water  bag,  169 
Hour-glass  stomach,  340 
Houston's  valves,  33 
Hunger,  canine,  360 
Hydatid  disease,  685 

treatment,  690 
Hydrochloric  acid,  cells  secreting,  20 
combined,  96 

Topfer's  test  for,  99 
deficit,  determination,  107 
free,  96 

Boas'  test  for,  97 

Boas  and  Moerner's  test  for,  106 

color  tests  for,  97 

Congo  paper  tests  for,  106,  107 

Giinzburg's  test  for,  97 

in  gastric  ulcer,  227 

Mintz's  test  for,  106 

Moerner  and  Boas'  test  for,  106 

phloroglucin-vanillin  test  for,  97 

quantitative  test  for,  97,  98,  99 

resorcin-sugar  test  for,  97 

Riegel's  test  for,  107 

tests  for,  97 

Topfer's   quantitative   test   for, 

97,  98,  99 
tropaolin-00  test  for,  106 
in  gastric  cancer,  252 
Hydrogen-sulphid       auto-intoxication, 

449 
Hydrotherapy  in  acute  enteritis,  486 

in  atonic  ectasy  of  stomach,  331 

in  chronic  enteritis,  494,  496 
gastritis,  197 

in  constipation,  468 

in  gastroptosis,  358 

in  gastrosuccorrhea  continua  period- 
ica, 295 

in  hyperchlorhydria,  286 


Hydrotherapy    in    intestinal    diseases, 
440 

in  mucous  colic,  677 

local,  168 
Hydrothionemia,  450 
Hymenolepsis  diminuta,  690 

nana,  689 
Hypanakinesis  ventriculi,  372 
Hyperaciditas  hydrochlorica,  279.    See 

also  Hyperchlorhydria. 
Hyperacidity,    279.     See    also    Hyper- 
chlorhydria. 
Hyperalgesia,    cutaneous.         See    also 

Head's  zones. 
Hyperanakinesis  ventriculi,  369,  373 
Hyperchlorhydria,  279 

absorption  in,  283 

acid  gastritis  and,  differentiation,  285 

alkali  treatment,  289 

atony  with,  284 

biliary  colic  and,  differentiation,  285 

bowels  in,  care  of,  291 

complications,  284 

constipation  in,  treatment,  291 

course,  283 

diagnosis,  284 

diet  in,  139,  286 

differential  diagnosis,  285 

dilatation  complicating,  284 

electricity  in,  291 

etiology,  280 

frequency,  280 

gastralgia  and,  differentiation,  367 

gastric  analysis  in,  282 
ulcer  and,  214,  218 

differentiation,  216,  221,  222,  285 

gastroptosis  complicating,  284 

gastrosuccorrhea  and,  differentiation, 
285 

hydrotherapy  in,  286 

hypersecretion   and,    differentiation, 

285 

in  gastric  cancer,  252,  253 

magnesia  in,  289 

medication  in,  289 

motor  function  in,  283 

movable  kidney  complicating,  284 

nervous   gastralgia  and,   differentia- 
tion, 285 

pain  in,  treatment,  290 

pathology,  284 

prognosis,  283 


INDEX 


741 


Hyperchlorhydria,   proteid   treatment, 
286 

removal  of  causes,  285 

soda  in,  289,  290 

symptoms,  281 

treatment,  285 

Vichy  water  in,  289 

Wolff's  Carlsbad  salts  in,  290 
Hyperesthesia  of  intestines,  669 

of  stomach,  364 
Hyperinosis  in  appendicitis,  605 
Hyperkinesis,   369 
Hypermotility  of  stomach,  369 
Hyperorexia,  360 
Hyperpepsinia,  104 
Hyperplasia  in  typhoid  fever,  529 
Hypersecretion,  291.     See  also  Gastro- 

succorrhea. 
Hypersthenic  gastritis,  190 
Hypertrophy  of  colon  with  congenital 
dilatation,  456 

of  mucosa  in  chronic  enteritis,  488 

with  mucoid  degeneration  and  cyst 
formation    in    amebic    dysentery, 

509 
Hypodermoclysis,  439 

in  iliolumbar  region,  540 
Hypogastric  neuralgia,  670 
Hypopepsinia,  104 

Ice  tubes  for  hemorrhoids,  580,  581 
Idiopathic  nervous  vomiting,  379 
Ileaca-ileocolic  intussusception,  642 
Ileocecal  intussusception,  642 

tuberculosis.  Head's  zone  in,  615 
Ileocolic  intussusception,  642 
Ileum,  anatomy,  23 

arterial  supply  of,  24 

cancer  of,  566 

perforation  of,  Head's  zone  in,  615 

tuberculosis  of,  549 
Ileus,    635.     See    also    Intestines,     ob- 
struction of. 
Iliac  phlegmon,  591 
Illoway's  estimation  of  pepsin,  103 

test  in  appendicitis,  601 
Incontinence  of  pylorus,  371 
Indicanuria,   auto-intoxication  in,  445, 
446 

causes,  37,  39 

in  acute  intestinal  obstruction,  635 

intestinal,  445 


Indicanuria,  intestinal,  diet  in,  446 

medication  in,  447 

Rosenbach's  test  for,  446 

test  for,  446 

treatment,  446 
Indol  in  feces,  tests  for,    426 
Indolic  putrefaction,  auto-intoxication 
in,  445,  446 

combined    with    saccharobutyric, 

447 
auto-intoxication  in,  447 
Infarction    of    bowel,    554.     See    also 

Embolism  and  Throm,bosis. 
Infectious  diseases,  ectasy  of  stomach 
with,  312 
intestinal  ulcers  in,  550 
symptoms,  551 
treatment,  553 
Inferior  mesenteric  artery,  occlusion  of, 

557 
Infiltration  treatment  of  hemorrhoids, 

586 
Inflation  of  colon  with  water,  408 

of  intestines,  uses,  407 
with  air,  406 
with  carbonic  acid  gas,  406 

of  stomach,  conclusions  regarding,  89 
with  air,  78 

with  carbonic  acid  gas,  77 
with  water,  78 
Influenza,  stomach  functions  in,  391 
Infrapapillary  cancer  of  duodenum,  565 
Infusion,  rectal,  439 
Infusoria,  681 

in  gastric  contents,  117 
Ingesta,  examination  of,  95 
Insane,  atonic  ectasy  of  stomach  in,  323 
Inspection,  general,  45 

of  abdomen,  49 

of  abdominal  blood-vessels,  49 

of  anus,  396 

of  esophagus,  46 

of  gall-bladder,  57 

of  kidneys,  66 

of  liver,  57 

of  neck,  46 

of  oral  cavity,  45 

of  pharynx,  46 

of  rectum,  396 

of  sjjleen,  62 

of  stomach,  72 

conclusions  regarding,  88 


742 


INDEX 


Inspection  of  tongue,  45 
of  tonsils,  46 
of  uvula,  46 
Insufficiency,  motor,  304 
definition,  321 
of    first    degree,     304.     See    also 

Atony  of  stomach,  chronic. 
of  second  degree,   320.     See  also 
Ectasy  of  stoinach,  chronic. 
of  cardia,  375 

of  kidneys  in  typhoid  fever,   treat- 
ment, 541 
of  pylorus,  371 
Intercostal   neuralgia,    gastralgia   and, 

differentiation,  368 
Intermittent  hypersecretion,  292.     See 
also  Gastrosuccorrhea  contintia  period- 
ica. 
Internal  anal  sphincter,  32 
Interrogation  of  patient,  42 
Intestinal  colic,  453.     See  also  Enter- 
algia. 
contents,    irritation    from,    diarrhea 

due  to,  473 
dyspepsia,  444 
indicanuria.'    See    also    Indicanuria, 

intestinal,  445 
irrigation  in  achylia  gastrica,  210 
juice,  38 

aspiration  of,  420 
in  fasting  stomach,  113 
in  gastric  contents,  113 
obtaining  of,  420 
mechanical  procedures,  428 
neurasthenia,  671 

obstruction,    635.     See    also    Intes- 
tines, obstruction  of. 
pain,  453.     See  also  Enteralgia. 
putrefaction,      arthritis      deformans 
and,  448 
in  achylia  gastrica,  treatment,  210 
indolic  type,   combined  with  sac- 

charobutyric,  447 
saccharobutyric  type,  447 

combined  with  indolic,  447 
sand,  456 
false,  457 
Intestines,  absorption  in,  39 
adenoma  of,  571 
adenomyoma  of,  560 
anatomy  of,  22 
angioma  of,  572 


Intestines,  anomalies  in  form  of,  456 

in  position  of,  456 
bacteria  of,  38 
bismuth   subnitrate   in   examination 

of,  405 
blood-vessels  of,  diseases  of,  554 
cancer  of,  551,  559.     See  also  Cancer 
of  intestines. 

symptoms,  551 

treatment,  553 
catarrh  of,  478.     See  also  Enteritis. 
chylangioma  of,  572 
compression  of,  636 

mechanism,  639 
digestion  in,  36 
diseases  of,  394 

alimentary  rest  in,  442 

artificial  feeding  in,  444 

auscultation  in,  404 

auscultatory  percussion  in,  403 

diet  in,  442 

electricity  in,  440 

exercise  in,  439 

gelatin  as  food  in,  443 

gurgling  sounds  in,  404 

gymnastics  in,  439 

hydrotherapy  in,  440 

interrogation  of  patients  in,  394 

mechanical  supports  in,  440 

milk  in,  442,  443 

percussion  in,  402 

splashing  sounds  in,  400 

succussion  in,  400 
distomiasis  of,  693 

diverticula  of,  623.     See  also  Diver- 
ticula of  intestines. 
examination  of,  394 

physical,  395 
faradism  to,  163,  164 
ferments  of,  organized,  38 
fibroma  of,  572 
fibromyoma  of,  572 
functions  of,  motor,  bead  test  for,  420 

test  diet  for,  421 

testing,  420 
gas  cysts  of,  573 
gonorrhea  of,  551 

symptoms,  551 

treatment,  553 
Head's  zone  for,  615 
hemorrhage  of,  542 

treatment,  553 


INDEX 


743 


Intestines,  hyperesthesia  of,  669 
in  amebic  dysentery,  505 
in  appendicitis,  602 
in  typhoid  fever,  529 
in  uncinarial  dermatitis,  705 
inflation  of,  uses,  407 

with  air,  406 

with  carbonic  acid  gas,  406 
inspection  in  disease  of,  395 
intussusception    of,    641.     See    also 

Intussusception. 
irrigation  of,  428.     See  also  Irriga- 
tion of  intestines. 
large,  absorption  in,  40 

acute  obstruction  of,  diagnosis,  649 

anatomy  of,  29 

appendices  epiploicse  of,  29 

bands  of,  29 

coats  of,  33 

descent  of,   349.     See  also  Enter- 
optosis. 

divisions  of,  29 

external  pouches  of,  29 

function  of,  in  digestion,  34 

haustra  coli  of,  29 

histology  of,  33 

length  of,  22 

mucous  coat  of,  33 

submucous  coat  of,  33 

teniae  of,  29 
lavage  of,  for  diagnosis,  408 
lipoma  of,  572 
lymphosarcoma  of,  570 
malignant  growths  of,  559 
massage     of,     165,     439.     See     also 

Massage. 
mechanical  support  of,  170 

indications,  170 
motor  function  of,  40 
movements  of,  Rontgen  rays  in  in- 
vestigating, 406 
myiasis  of,  551 

treatment,  553 
myoma  of,  572 
neoplasms  of,  559 

benign,  571 

malignant,  559 
nervous  diseases  of,  666 
neuroses  of,  motor,  666 

secretory,  671 

sensory,  669 
obstruction  of,  635 


Intestines,  obstruction  of,  acute,  635 
anuria  in,  635 

arsenic-poisoning  and,  differen- 
tiation, 652 
auscultation  in,  649 
by  fecal  accumulation,  differen- 
tial diagnosis,  651 
by   foreign    bodies,    differential 

diagnosis,  651 
collapse  in,  647 
course,  652 
definition,  635 
diagnosis,  635,  647 
differential  diagnosis,  635,  636, 
652 
between  forms  of,  650 
occlusion    of    small    and 
large  intestine,  649 
due  to  chronic  obstruction,  646 
etiology,  636 
indicanuria  in,  635 
inspection  in,  648 
intra-abdominal      pressure      in, 

636 
lead-poisoning  and,   differentia- 
tion, 652 
medical  treatment,  653 
of  large  intestine,  649 
of  small  intestine,  649 
operation  in,  655 
pain  in,  646,  647,  648 
palpation  in,  648 
pathology,  646 
percussion  in,  648 
peristalsis  in,  647 
peritonitis   and,    differentiation, 

652 
physical  signs  of,  648 
prognosis,  653 
surgical  treatment,  655 
symptoms,  646 
treatment,  653 
inedical,  653 
surgical,  655 
tympanites  in,  647 
types,  635 
vomiting  in,  647 
bowels  in,  treatment,  663 
by  adhesions,  637 
by  l)ands,  637 
by  compression,  636 
by  enteroliths,  645 


744 


INDEX 


Intestines,    obstruction    of,    by    fecal 
masses,  645 
chronic,  661 
by  foreign  bodies,  644,  645 
differential  diagnosis,  651 
treatment,  655 
by  herniaform  strangulation,  636 
by  internal  hernia,  638 
by  intussusception,  641.     See  also 

Intussusception. 
by  paresis,  645 
by  rectal  stricture,  66 1 

treatment,  664 
by   strangulation   of   Meckel's   di- 
verticulum, 637 
through  apertures,  637 
slits,  637 
by  volvulus,  639 

carcinomatous,  diverticular  steno- 
sis and,  differentiation,  631 
chronic,  657 
anatomy,  657 

barrel-shaped  abdomen  in,  660 
by  fecal  accumulation,  661 
colic  in,  treatment,  664 
complications,  662 
constipation  in,  659 
course,  663 
diagnosis,  662 
diarrhea  in,  659 
diet  in,  663 
etiology,  657 
gastric  analyses  in,  659 
inspection  in,  660 
location  of,  658,  659 
operation  in,  665 
peristaltic  unrest  in,  659 

treatment,  664 
prognosis,  663 
Rontgen  rays  in,  660 
surgical  treatment,  665 
symptoms,  658 
treatment,  663 
tjnmpanites  in,  660 
vomiting  in,  659 
treatment,  664 
dynamic,  645 

differential  diagnosis,  651 
treatment,  654 
in  diverticulitis,  633 
with  stenosis  in  diverticulitis,  630 
obturation  of,  644 


Intestines,   obturation    of,   differential 
diagnosis,  650 
treatment,  655 
oscillating  movements  of,  40 
papilloma  of,  572 
parasites  of,  681 

diarrhea  from,  474,  476 
paresis  of,  645,  666 

differential  diagnosis,  651 
treatment,  654 
peristalsis  in,  40 
physical  examination  of,  395 
polypi  of,  571 

Rontgen  rays  in  examination,  405 
rotary  movements  of,  40 
sarcoma  of,  570 
serous  coat  of,  33 

small,  acute  obstruction  of,  diagnosis, 
649 
anatomy  of,  microscopic,  26 
arterial  supply  of,  24 
Brunner's  glands  in,  27 
catarrh  of,  diagnosis,  483,  484 
coats  of,  25 
fermentation  in,  38 
function  of,  in  digestion,  34 
length  of,  22 

Lieberkuhn's  glands  of,  27 
lymphatics  of,  24 
mucous  coat  of,  25 
muscular  coat  of,  25 
nerves  of,  24 
peritoneal  coat  of,  25 
Peyer's  patches  in,  28 
serous  coat  of,  25 
structure  of,  25 
submucous  coat  of,  25 
veins  of,  24 
villi  of,  26 
volvulus  of,  640 
solitary  follicles  of,  27 
splashing   sounds  of,    differentiation 

from  stomach  splash,  81 
stenosis  of,   chronic,   657.     See  also 

Intestines,  obstruction  of,  chronic. 
strangulation     of.     See     Strangula- 
tion. 
strapping,  to  support,  170 
structure  of  wall  of,  diverticula  and, 

627 
syphilis  of,  551 
symptoms,  551 


INDEX 


745 


Intestines,  syphilis  of,  treatment,  553 

transillumination,  404 

tuberculosis  of,  548,  549 
symptoms,  551 
treatment,  553 
tubercle  bacilli  in  feces  in,  553 

tumors  of,  benign,  571 
malignant,  559 

tympanites  of,  451.     See  also  Tym- 
panites. 

ulcers  of,    543.     See   also    Ulcers  of 
intestines. 
Intra-abdominal      pressure,      mainte- 
nance of,  344 
Intragastric  method  of  applying  elec- 
tricity in  stomach  diseases,  161 
Intrarectal  electricity,  441 
Intussusception,  641 

age  and,  643 

bowels  in,  644 

chronic,  660 

course,  652 

diagnosis,  644 

differential  diagnosis,  650 

duration,  644 

etiology,  642,  643 

fecal  vomiting  in,  644 

frequency,  643 

ileaca-ileocolic,  642 

ileocecal,  642 

ileocolic,  642 

mechanism  of,  642 

pain  in,  643 

prognosis,  644,  653 

symptoms,  643 

treatment,  655 

tumor  in,  644 

vomiting  in,  643,  644 
Intussusceptum,  641 
Intussuscipiens,  641 
Inunctions,  nutritive,  138 
Invagination,  641.     See  also  Intussus- 
ception. 
Involutions  of  appendix   vermiformis, 
harmful,  auto-intoxication  in, 
608 
symptoms,  608 
lodin-potassium  solution,  Lugol's,   106 
lodipin  test  for  motor  power,  123 
Iodoform  reaction  for  aldehyd,  102 
Irrigation  in  acute  amebic  dysentery, 

517 


Irrigation  in  acute  enteritis,  486 
in  bacUlary  dysentery,  526 
in  mucous  colic,  676,  679 
in  typhoid  fever,  536,  537 
of  intestines,  428 

by  patient,  436 

double-current,  432 

in  achylia  gastrica,  210 

position  of  patient,  434 

rotation  method,  434 

solutions  for,  435 

uses,  428 

value  of,  436 

with  single  tube,  430 
of  prostate  by  patient,  436 
of  stomach,   140.     See  also  Lavage. 
rectal,  in  acute  gastric  ectasy,  318, 

319 
recurrent    electric,    in    constipation, 
468 
Irrigators,  rectal,  431 

double-current,  432 
Irritants  transmitted  in  blood,  diarrhea 
from,  474 
treatment,  476 
Irritation  of  intestinal  contents,  diar- 
rhea from,  473 
Ischochymia,  320.     See  also  Ectasy  0} 

stomach,  chronic. 
Itch,  ground,  703 

Jacoby-Solms  test  for  pepsin,  104 

Jalap  in  constipation,  471 
Jejunum,  anatomy,  23 

arterial  supply  of,  24 

cancer  of,  566 

tuberculosis  of,  549 
Juvenile  vomiting,  379 

Kamala  for  tapeworm,  691 
Katayama  disease,  695 
Kelly's  rectal  specula,  396 

proctoscope,  397 
Kelsey's  rectal  speculum,  398 
Kemmerich's  peptone  preparation,  133 
Kemp's  circumscribing  gastrodiaphane, 

83,  84 
continuous  steam  coil,  169 
dietary  in  typhoid  fever,  536 
double-current  irrigation  tube,  432 
flexible  recurrent  rectal  irrigator,  431 
glass  rectal  irrigator,  431 


746 


IND^X 


Kemp's  ice  tube  for  hemorrhoids,  580 
intrarectal  instrument,  441 
metal  rectal  irrigator,  431 
method  for  expressing  gastric  con- 
tents, 94 
of  using  trypsin  in  treating  cancer, 
269 
nutritive  rectal  enema,  137 
recurrent  electric  irrigation  in  con- 
stipation, 468 
soft -rubber  rectal  bag,  581 
stomach-whistle,  79 
strapping  method,  170,  171 
test  meal,  91 

for  motor  power,  122 
treatment  of  gastric  ulcer,  231 
tube  cooler  for  hemorrhoids,    580 
for  prostate,  580 
Kerkring's  valvulae  conniventes,   25 
Kidneys,  anatomic  relations  of,  64 
diseases  of,  stomach  functions  in,  390 
effect  of  salt  on,  130 
floating,  67,  344.     See  also  Nephrop- 
tosis. 
Head's  zone  for,  614 
in  diagnosis  of  chronic  ectasy,  326 

of  gastroptosis,  342 
in  typhoid  fever,  530 
in  uncinarial  dermatitis,  704 
inspection  of,  66 
massage  of,  357 
mobility  of,  67 

movable,  67,  344.     See  also  Nephrop- 
tosis. 
palpation  of,  66 
new  method,  68 
old  method,  66-68 
percussion  of,  69 
position  for,  69 
physical  examination  of,  66 
surface  relations  of,  65 

posterior,  65 
topography  of,  64 
Kilmer's  abdominal  belt,  175 
Kjeldahl    digestion    flask    for    testing 

feces  for  putrefactive  products,  426 
Klemperer's  oil  test  for  motor  power, 
123 
test  meal,  90 
KJunge's  aloin  test  for  blood,  115 
Knapp's  director  for  aiding  passage  of 
lavage  tube,  152,  153 


Knapp's  method  of  inspecting  liver,  57 

test  for  succinic  acid,  121 
Koch's  peptone  preparation,  133 
Kousso  for  tapeworms,  691 
Kymograph,  123 

La  Grecque  corset,  179,  355 
Lacing  liver,  352 

Lactic  acid,  Arnold's  test  for,  10 1 
bacillus,  420 
Boas'  test  for,  102 
Boas-Oppler  bacUli  in  generation 

of,  119 
estimation  of,  102 
in  cancer  of  stomach,  253 
significance  of,  102 
Strauss  mixing  funnel  for,  loi 
tests  for,  100 
Uffelmann's  test  for,  100 
modified,  loi 
Laparotomy,    exploratory,    in    gastric 
cancer,  261 
in  intestinal  cancer,  569 
in  gastric  ulcer,  235 
in  pyloric  stenosis,  262 
Large  calorie,  124 

intestine,     22.     See    also    Intestine, 
large. 
Lavage,  140 

accessories  for,  142 

by  single  operator,  144 

contra-indications  for,  155 

cyanosis  from  passing  of  tube  in,  144 

dangers  of,  141 

Dawbarn's  method,  150 

double-current  tubes  for,  153 

duration  of,  144 

emergency,  146 

emptying  funnel  in,  145 

for  office  practice,  142 

Friedlieb's  apparatus  for,  146,  148 

modified,  149 
funnel,  140,  144 

method,  140 
in  acute  ectasy,  3 1 8 
in  appendicitis,  617,  618 
in  atonic  ectasy  of  stomach,  332 
in  chronic  gastritis,  196 
in  gastric  ulcer,  234 
in  gastrosuccorrhea  continua  chron- 
ica, 301 
periodica,  295 


INDEX 


747 


Lavage  in  nervous  cases,  147 

in  simple  acute  gastritis,  184 

in  stenotic  ectasy  of  stomach,  335 

in  toxic  gastritis,  1S6 

indications  for,  153 

interruption  of  flow  during,  146 

Knapp's  director  as  aid  in,  152,  153 

Leube-Rosenthal  method,  150 

mouth-gag  in,  152 

occlusion    of    stomach-tube    during, 
146 

of  bowel  for  diagnosis,  408 

passing  of  tube,  143 

position  of  operator,  143 
of  patient,  142 

slipping  of  tube  into  stomach  in,  141 

stomach-tube  for,  caliber  of,  142 
cleansing,  142 
removal,  145,  146 
selection,  141 

technic,  142 

testing  of  tube  before,  141 

through  nostril,  153 

with  glass  Y  or  J,  150 

with  patient  on  back,  152 
Laxative  foods,  442 
Laxatives  in  constipation,  469 
Lead-poisoning,   intestinal  obstruction 

and,  differentiation,  652 
Lee's  cholera  table,  430 
Legs,   flexion  of,   in  abdominal  palpa- 
tion, 50 
Lenhartz's  treatment  of  gastric  ulcer, 

228 
Lesser  curvature  of  stomach,  18 

omentum,  19 
Leube's  diet  scale  of  foods  according  to 
digestibility,  135 

meat    pancreas    as    nutritive    rectal 
enema,  137 

sound  method  for  determining  posi- 
tion of  stomach,  79 

test  meal  foi"  rnotor  power  of  stom- 
ach, 122 
Leube-Rosenthal  meat  solution,   136 

method  of  lavage,  150 
Leube-Ziemssen    rest    cure    in    gastric 

ulcer.  228 
Leukocytosis,  Gibson's  differential  chart 
for,  605 

in  appendicitis,  605 
Leukopenia  in  typhoid  fever,  533 


Levulose,  absorption  of,  40 
Licorice  powder  in  constipation,  470 
Lieberkiihn's  glands,  27 

crypts  in  acute  enteritis,  480 
Ligature  of  hemorrhoids,  585 
Linea  alba,  47 
Lineae  semilunares,  47 
Lipoma  of  intestines,  572 

of  stomach,  275 
Liver  abscess  in  amebic  dysentery,  509 
in  bacillary  dysentery,  524 

anatomy  of,  55 

carcinoma  of,  from  intestinal  cancer, 
560 

cirrhosis  of  gastric  ulcer  and,  differ- 
entiation, 223 
syphilitic,     gastric     cancer     and, 
differentiation,  256 

delimitation  of,  55 

diseases,  stomach  functions  in,  390 

displacement  of,  60 

dulness,  59 

floating,  352 

fluke  worm,  692 

Head's  zones  for,  613 

in  typhoid  fever,  530,  533 

in  uncinarial  dermatitis,  704 

inspection  of,  57 

lacing,  352 

movable,  352 

palpation  of,  58 

percussion  of,  59 
auscultatory,  59 

physical  examination  of,  57 

spilling  of,  58 

syphilitic  stenosis  of,  gastric  cancer 
and,  differentiation,  256 

tumor  of,  percussion  of,  60 
Lockwood's  gastrodiaphane,  83 

intragastric  electrode,  161,  162 
Locomotor  ataxia,  gastric  crises  of,  gas- 
tric ulcer  and,  223 
Ludwig's  kymograph,  123 
Lugol's  solution  of  iodin-potassium,  166 
Lunch  dietary,  128 

Lungs,   Head's  zones  in  affections  of, 
609 

in  uncinarial  dermatitis,  704 
Lymphatics  of  cecum,  32 

of  colon,  32 

of  rectum,  32 

of  small  intestine,  24 


748 


INDEX 


Lymphatics  of  stomach,  21,  262 

enlarged,      gastric       cancer     and, 
differentiation,  260 
Lymphosarcoma  of  intestines,  570 

Maggot- WORM,  699.     See  also  Ox)uris 

"vermicularis . 
Magnesia  in  hyperchlorhydria,  2 89 
Malacia,  361,  362 
Malaria,  stomach  functions  in,  391 
Male  fern  for  tapeworms,  690 
Malignant  growths  of  intestines,  559 
Maltose,  absorption  of,  40 

test  for,  106 
Massage,  165 

bags,  colonic,  439 

electric  roller,  hot-and-cold,  in  con- 
stipation, 467 

in  atonic  ectasy  of  stomach,  333 

in  chronic  enteritis,  495 
gastritis,  197 

in  constipation,  466 

in  gastroptosis,  356 

in  nephroptosis,  357 

indications  for,  165 

intestinal,  439 

roller,  167 

tapping  in,  165 

vibratory,  165 

in  chronic  gastric  atony,  305 
Matthieu  and  Remond's  determination 

of  chyme,  1 1 1 
Mayo's  partial  gastrectomy  for  cancer, 

263 
Mazamorra,  703 

McBm^ney's  point  in  appendicitis,  599 
Meals,  regularity  of,  136 
Meat  broth,  136 

chemic  composition  of,  130 

fibers  in  feces,  418 

pancreas,  Leube's,  as  nutritive  rectal 
enema,  137 

pastry,  butter,  and  soup  with  milk 
diet,  134 

poisoning    from    bacillus    botulinus, 

449 
powders,  209 

Debove's,  137 
Mechanical  procedures,  intestinal,  428 
Meckel's  diverticulum,  24,  624 

strangulation  by,  637 
Medullary  carcinoma  of  stomach,  242 


Megalogastria,  320,  340 

Megastoma  entericum  in  gastric   con- 
tents, 117 

Meissner's  plexus,  25 

Melancholia,  auto-intoxication  in,  323, 
446 

Melancholies,  atonic  ectasy  of  stomach 
in,  322 

Meltzer's  method  of  palpation  in  ap- 
pendicitis, 601 

Membranous  gastritis,  181 

Merycism,  376 

Mesenteric  arteries,  embolism  of,   554. 
See  also  Emholism. 
thrombosis     of,      554.     See     also 
Thrombosis. 
artery,  inferior,  occlusion  of,  557 

superior,  occlusion  of,  555 
glands  in  typhoid  fever,  530 
traction,  chronic,  349 
veins,    embolism   of,    554.     See   also 
Embolis'in. 
thrombosis     of,     554.      See     also 
Thronibosis. 

Mesenteritis  in  diverticulitis,  632 

Mesentery,   growths  of,   gastric  cancer 
and,  differentiation,  260 

Meso-appendix,  31 

Mesorectum,  32 

Metabolism,  proteid,  125,  126 

Metal  rectal  irrigator,  431 

Meteorism,    451.     See    also    Tympan- 
ites. 

Methylene-blue  in  gastric  cancer,  268 

Mett's  test  for  pepsin,  105 

Microgastria,  340 

Micro-organisms  in  feces,  419 
in  gastric  contents,  118 

Microscopic     examination     of     gastric 
contents,  116,  117 

Migraine,   acute  ectasy  of  stomach  in, 

310.  311 
auto-intoxication  in,  311 
Milk  as  diet  in  intestinal  diseases,  442, 

443 
chemic  composition  of,  131 
diet  in  gastric  ulcer,  226 

with    carbohydrates    and    fat     in 

mushes  and  soups,  133 
with  liquid  carbohydrates,  133 
with    meat,    pastry,    butter,    and 
soup,  134 


INDEX 


749 


Milk  diet  with  solid   food,  pastry,  and 
broths,  133 
digestibility  of,  135 
dilution  of,  135 
fat,  Gartner's,  136 
in  typhoid  fever,  537 
Milk-curdling  ferments,  cells  secreting, 

20 
Milk-sugar,  absorption  of,  40 
Mineral  waters  in  chronic  gastritis,  199 
Miner's    anemia,    701.     See    also    Un- 
cinariasis. 
Mintz's  test  for  free  hydrochloric  acid, 

106 
Miserere,     635.     See     also     Intestines, 

obstruction  of,  acute. 
Moerner  and  Boas'  test  for  free  hydro- 
chloric acid,  106 
Moist  hot  applications,  169 
Morgagni,  columns  of,  33 
Moritz-Hemmeter      test      for      motor 

power,  123 
Morris'  point  in  appendicitis,  599,  600 
Motor  functions  of  stomach,  122.     See 
also  Stomach,  functions  of,  motor. 
insufficiency    of    first    degree,     304. 
See     also     Atony     of     stomach, 
chronic. 
of  second  degree,    320.     See  also 
Ectasy  of  stoinach,  chronic. 
neuroses  of  intestines,  666 
of  stomach,  369 
Mould  in  gastric  contents,  118,  120 
Mouth-gag  in  lavage,  152 
Movable    kidney,    67,    344.     See    also 
Nephroptosis. 
liver,  352 
Mucin  in  feces,  410 

test  for,  41 1 
Mucoid  degeneration  in  amebic  dysen- 
tery, 509 
Mucous  coat  of  large. intestine,  33 
of  small  intestine,  25 
of  stomach,  20 
colic,  672.     See  also  Colic,  tnu^ous. 
gastritis,  194 
glands  of  stomach,  20 
Mucus  in  feces,  410,  419 

in  chronic  enteritis,  487,  490,  491 
in  intestinal  ulcer,  553 
in  gastric  contents,  113,  116 
in  vomit,  112 


Mucus,  microscopic  appearance,  116 
separate  particles,  examination,  412 

Multiple  neuritis  in  gastric  cancer,  249 

Munro's  point  in  appendicitis.  600 

Murphy's  drop  method  of  injecting 
saline  solution  in  rectum,  437.  See 
also  Proctoclysis. 

Muscle  fatigue,  auto-intoxication  in, 
448 

Muscular  coat  of  small  intestine,  25 
of  stomach,  19 

Mushes  and  soups  with  milk  diet,  133 

Mustard  poultice,  170 

Myalgia,  gastralgia  and,  differentia- 
tion, 368 

Myasthenia  ventriculi,  304 

Myelitis,  gastralgia  from,  366 

Myiasis,  intestinal,  551 
symptoms,  551 
treatment,  553 

Myoma  of  intestines,  572 
of  stomach,  275 

Naphthalin  for  tapeworm,  691 
Nauheim  baths  in  typhoid  fever,  537 
Nausea  due  to  abnormal  sensation,  364 
Nebulizer,  colonic,  439,  440 
Neck,  inspection  of,  46 
Necrosis  in  typhoid  fever,  530 
Needle  douche,  intestinal,  439 
Nematodes,  696 
Neoplasms  of  intestines,  559 
benign,  571 
malignant,  559 
Nephritis,  stomach  functions  in,  390 

transient,  auto-intoxication  in,  446 
Nephropexy  in  gastroptosis,  346 
Nephroptosis,  344,  350 

complicating  hyperchlorhydria,  284 

degrees  of,  351 

diagnosis  of  chronic  ectasy  and,  326 

Dietl's  crisis  in,  345,  352 

hyperchlorhydria  complicating,  2S4 

massage  in,  357 

right,    distended    gall-bladder    and, 
differentiation,  70 
Nerves  of  cecum,  32 

of  colon,  32 

of  rectum,  33 

of  small  intestine,  24 

of  stomach,  22 
Nervous  affections  of  stomach,  359 


750 


INDEX 


Nervous  anorexia,  362 
belching,  375 
cases,  lavage  in,  147 
diarrhea,  474,  667 
treatment,  476 
diseases  of  intestines,  666 
dyspepsia,  381.     See  also  Dyspepsia, 

nervous. 
enteralgia,  670 

gastralgia,  gastric  cancer  and,  differ- 
entiation, 259 
system  in  typhoid  fever,  531,  541 
tympanites,  451 
vomiting,  377 
idiopathic,  379 
Neuhof  and  Elsberg's  method  of  diag- 
nosis by  Head's  zones,  610 
Neuralgia,  hypogastric,  670 

intercostal,    gastralgia    and,    differ- 
entiation, 368 
mesenterica,  670 

of  stomach,   365.     See  also  Gastral- 
gia. 
Neurasthenia,      auto-intoxication      in, 

323,  446 
gastrica,   38r.     See   also   Dyspepsia, 

nervous. 
intestinal,  67 
Neuritis  in  typhoid  fever,  533 

multiple,  in  gastric  cancer,  249 
Neurosis  of  intestines,  motor,  666 
secretory,  671 
sensory,  669 
of    stomach,    chronic  gastritis   and, 
differentiation,  195 
gastralgia  as,  366 
motor,  369 
secretory,  380 
sensory,  360,  364 
Nitrate  of  silver  treatment  of  chronic 

gastric  erosions,  238 
Nitric    acid,    fuming,    for    cauterizing 

hemorrhoids,  585 
Non-irritating  diet,  abundant,  134 
Normal  saline  solution  enema,  137 
injection  into  intestines,  429 
Nutrition,  principles  of,  1 24 
Nuts,  chemic  composition  of,  132 
food  value  of,  129 

Obesity,  diverticula  and,  627 
Objective  Head  zones,  61 1 


Obstipatio  alvi,  458.     See  also  Consti- 
pation. 
Obstruction,  635.     See  also  Intestines, 

obstruction  of. 
Obturation  of  intestines,  644 
differential  diagnosis,  650 
treatment,  655 
Obturator,  rectal,  670 
Occult  blood,  114 
tests  for,  114 
Oidium   albicans    in   gastric   contents, 

120 
Oil  test  for  motor  power,  Klemperer's, 
123 
meal  to  secure  trypsin,  420 
Olive  oil  in  constipation,  466,  470 
•Omentum,  greater,  19 
lesser,  19 

protective  function  of,  in  amebic  dys- 
entery, 507 
Opiates  in  acute  enteritis,  485,  486 

in  diarrhea,  477 
Opium  in  appendicitis,  618 
Oral  cavity,  inspection  of,  45 
Organized  ferments  of  intestine,  38 
Orthopedic  methods,  170 
in  constipation,  469 
Oscillating  movements  of  intestines,  40 
Osseous  system  in  typhoid  fever,  533 
Overfeeding,  125 
Oxyuris  vermicularis,  699 
diagnosis,  700 
symptoms,  700 
treatment,  701 

Packs,  170 

Palpation  of  abdomen,  50 

reinforced,  50 
of  cecum,  398 
of  colon,  398 
of  esophagus,  46 
of  gall-bladder,  58 
of  kidneys,  66 

new  method,  68 

old  method,  66-68 
of  liver,  58 
of  rectum,  401 

by  sounds,  401 
of  spleen,  62 
of  stomach,  73 

conclusions  regarding,  88 
Pancreas,  anatomic  relations,  60 


INDEX 


751 


Pancreas,   meat,  Leube's,   as  nutritive 
rectal  enema,  137 
physical  examination  of,  61 
topography  of,  60 
tumor  of,  61 
Pancreatic  calculi  in  feces,  416 
disease,  steatorrhea  and,  414 
juice,  function  of,  37 
in  fasting  stomach,  113 
Papilloma  of  intestines,  572 
Paramoecium  coli,  682 

diarrhea  from,  684 
Parasecretion,    291.     See   also   Gastro- 

succorrhea. 
Parasites  in  feces,  411 
in  vomit,  112 
intestinal,  681 

diarrhea  from,  474,  476 
Parasitic  origin  of  cancer,  241 
Paratyphlitis,  591 
Paratyphoid  bacillus,  534 
Paresis,  auto-intoxication  in,  323 
of  intestines,  645,  667 

difTerential  diagnosis,  651 
treatment,  654 
of  sphincters,  668 
Parorexia,  361 
Passio  iliaca,  635.     See  also  Intestines, 

obstruction  of,  acute. 
Pastry,    broths,    and    solid   food    with 
milk  diet,  133 
meat,  butter,   and  soups  with  milk 
diet,  134 
Patient,  examination  of,  45 
preparation,  48 
technic,  48 
history  of,  42 
interrogation  of,  42 

in  intestinal  diseases,  394 
preparation  of,  for  examination,  48 
Pelletierin  for  tapeworm,  691 
Pemphigus   of  mouth,    stomach   func- 
tions in,  392 
Penicillium    glaucum    in    gastric    con- 
tents, 119 
Penzoldt's  scale  of  digestibility,  135 
Penzoldt  and  Faber's  test  of  absorptive 

function  of  stomach,  121 
Pepper  poultice,  1 70 
Pepsin,  103 

casein  test  for,  104 
cells  secreting,  20 


Pepsin,  Fuld's  test  for,  104 

Gross'  test  for,  104 

Illoway's  estimation,  103 

in  gastric  juice,  35 

Jacoby-Solms  test  for,  104 

Mett's  test  for,  105 

ricin  test  for,  104 

Solms-Jacoby  test  for,  104 

tests  for,  103 
Pepsinia,  normal,  104 
Peptic  ulcer,    212.     See  also    Ulcer  of 

stomach. 
Peptone,  absorption  of,  39 

biuret  reaction  with,  103 

in  feces,  412 

in  gastric  contents,  103 

preparations,  133 
Percussion,  auscultatory,  52,  54 

flicking,  52,  53 

hammer,  52,  53 

of  abdomen,  52 

sources  of  error,  54 

of  gall-bladder,  59 

of  intestines,  402 

of  kidney,  69 
position  for,  69 

of  liver,  59 

auscultatory,  59 

of  spleen,  63 

of  stomach,  74 
auscultatory,  74 

scratch  method,  76 
conclusions  regarding,  88 

scratch  method,  52,  54 

simple,  52 
Percutaneous  method  of  applying  elec- 
tricity in  stomach  diseases,  161 
Perforating  gastric  ulcer,  212,  219.   See 

also  Ulcer  of  stomach. 
Perforation  in  gastric  cancer,  244,  249 
Peridiverticulitis,  620.     vSee  also  Diver- 
ticulitis. 
Perigastritis,   gastralgia  and,    differen- 
tiation, 36S 
Periodic  vomiting,  378 
Perisigmoiditis,   620.     See  also  Diver- 
ticulitis. 
Peristalsis,  diagnostic  value,  49 

influence  of  foods  on,  442,  443 

intestinal,  40 
centers  of,  41 

nervous  control  of,  41 


752 


INDEX 


Peristalsis  of  stomach,  72,  122 

reversed,  41 
Peristaltic  unrest,  gastric,  72,  370 
in  chronic  obstruction,  659 

treatment,  664 
intestinal,  666 
Peritoneal  coat  of  small  intestine,  25 

of  stomach,  19 
Peritoneum,  growths  of,  gastric  cancer 

and,  differentiation,  260 
Peritonitis,    acute,    intestinal   obstruc- 
tion and,  differentiation,  652 
from  cancer,  562,  564 
in  typhoid  fever,  540 
local  chronic,  diverticulitis  and,  632 
perforative,  in  diverticulitis,  631,  633 
Perityphlitis,  591.      See  also  Appendi- 
citis. 
Pernicious    anemia,    auto-intoxication 
in,  448 
grave  anemia  in  gastric  cancer  and, 
differentiation,  255 
Pertussis,    vomiting  in,    Kilmer's   belt 

for,  175-179 
Peyer's  patches,  28 

in  typhoid'  fever,  529 
Phantom  tumor,  55,  451 
Pharynx,  inspection  of,  46 
Phlebectasia  hemorrhoidalis,  574.    See 

also  Hemorrhoids. 
Phlegmon,  iliac,  591 
Phlegmonous  enteritis,  500 

gastritis,     188.     See    also    Gastritis, 
phlegmonous. 
Phloroglucin-vanillin  test  for  free  hy- 
drochloric acid,  97 
Phthalic     anhydrid     and    resorcin     as 
fluorescent  medium  in  gastrodiaph- 
any,  85 
Phthisis,  stomach  functions  in,  388 
ventriculi,    191,   203,   204.     See  also 
Achyiia  gastrica. 
Physical    examination,    general    meth- 
ods, 45 
of  gall-bladder,  57 
of  intestines,  395 
of  kidneys,  66 
of  liver,  57 
of  pancreas,  61 
of  spleen,  62 
of  stomach,  71 

preparation  of  patient,  72 


Physiology  of  digestion,  34 

Pica,  362 

Pig  head  tapeworm,  689 

Pig's   blood,    heterologous,    in    gastric 

cancer,  274 
Piles,  574.     See  also  Hemorrhoids. 
Pine-needle  oil  for  tapeworms,  691 
Pin-worm,      699.     See     also     Oxyuris 

vermicularis. 
Pneumatic  proctoscope,   Tuttle's,   397, 

399 
Pneumatosis,  380 

cystoides  intestinorum  hominis,  573 
Pneumograph,  123 
Pneumonia,  acute  gastric  ectasy  in,  313 

stomach  functions  in,  387 
Podophyllin  in  constipation,  470 
Poisons,  antidotes  for,  187 
Politzer  bulb  for  aspiration,  92 
Polyphagia,  362 
Polypi  fragments  in  feces,  410 

of  intestines,  571 
Polypoid  excrescences  of  stomach,   275 
Polyposis  intestinalis  adenomatosa,  572 
Pomegranate  root  for  tapeworm,  691 
Pork  tapeworm,  686 
Portable  bath-tub.  Chambers',  538 
Portal  vein,  thrombosis  of,  555,  557 
Posttyphoid  pyemia,  534 

septicemia,  534 
Pouch  of  Douglas,  32 
Poultices,  169 

mustard,  170 

pepper,  170 
Powder-blower,  stomach,  159 
Einhorn's,  159,  160 
indications,  161 
Presecretin,  37 
Pretubercular  dyspepsia,  388 
Priessnitz's  compress,  168 
Procidentia  recti,  586 
Proctitis,  498 

classification,  498 

diagnosis;  483 

digital  examination  in,  499 

etiology,  498 

pathology,  498 

symptoms,  499 

treatment,  499 

with  hemorrhoids,  590 
Proctoclysis,  437 

bottle,  heat-retaining,  437 


INDEX 


753 


Proctoclysis,  flatus  in,  438 

length  of  tube  for,  438 

number  of  drops  per  minute,  438 

speed  of,  438,  439 

temperature  of  water  in,  438 

vacuum  bottle  for,  437 

value  of,  437 
Proctoscope,  Kelly's,  397 

pneumatic,  397,  399 
Proctoscopy,  396 

Proctosigmoidoscope,  pneumatic,  399 
Proctospasmus,  461 

treatment,  472 
Prolapse    of    rectum,     586.     vSee    also 
Rectum,  prolapse  of. 

of  stomach.     See  Gastroptosis. 
Propeptone  in  feces,  412 

in  gastric  contents,  103 
Prostate,  cooler  for,  581 

Kemp's  tube  for,  580 

self-irrigation  of,  436 
Proteids,  absorption  of,  39 

diet,  125,  126 

in  feces,  fermentation  test  for,  425 

metabolism,  125,  126 

requirement,  126,  127 
Protozoa,  681 

Pruritus,  auto-intoxication  in,  341 
Pseudo-angina,     auto-intoxication     in, 
312 

pectoris  with  acute  ectasy  of  stom- 
ach, 312 
Psoriasis,  stomach  functions  in,  391 
Psorospermiasis,  internal,  681 
Ptyalin,  34 

Pulmonary  tuberculosis,  stomach  func- 
tions in,  388 
Pumpkin  seeds  for  tapeworm,  691 
Purulent  enteritis,  500 
Pus  in  feces,  410,  419 

in  intestinal  cancer,  567 
ulcer,  552 

in  gastric  contents,  1 1 5 
Putrefaction,  arthritis  deformans  and, 
44S 

indolic,     auto-intoxication     in,    445, 
446 
combined     with     saccharobutyric, 

447 
saccharobutyric,  447 

combined  with  indolic,  447 
auto-intoxication  in,  447 

4s 


Pyemia,  posttyphoid,  534 
Pylorospasmus,  372 
Pylorus,  17 
cancer  of,  251 

partial  gastrectomy  for,  263 
glands  of,  20 
incontinence  of,  371 
insufficiency  of,  371 
narrowing  of,  congenital,  340 
resection  of,  for  cancer,  263 
spasm  of,  372 
stenosis  of,  326,  328,  329 
diet  in,  138 
laparotomy  in,  262 
syphilitic,  393 
valve  of,  17 
Pyrosis,  375 

QuiNiN  bisulphate   as  fluorescent  me- 
dium in  gastrodiaphany,  85 

Radiodiaphane,  88 
Radiodiaphany,  88 

Radium  in  treatment  of  gastric  cancer, 
265 

photographs  of  stomach,  88 

receptacle,  Einhorn's,  266 

transillumination  of  stomach,  88 
Rectal  alimentation,  137 

bag,  soft -rubber,  Kemp's,  581 

bougie,  soft,  401 

enemata,  137 

examination,  digital,  51 

feeding  in  gastric  ulcer,  227,  2 28 

infusion,  439 

injections  in  acute  amebic  dysentery, 

517 
irrigation  in  acute  amebic  dysentery, 

517 
gastric  ectasy,  318,  319 
in  bacillary  dysentery,  526 
in  typhoid  fever,  536,  537 
irrigators,  431 

double-current,  432 
obturator,  670 
specula,  396-399 
Recti  muscle,  thickening  of,  diagnosis, 

277 
Rectum,  31 
ampulla  of,  32 
anesthesia  of,  669 
arteries  of,  32 


754 


INDBX 


Rectum,  cancer  of,  568 

perforation  into  bladder  in,  564 
into  uterus  in,  564 
into  vagina  in,  564 
treatment,  569 
coats  of,  33 

examination  of,  digital,  51 
in  appendicitis,  602 
in  chronic  enteritis,  487,  493 
inspection  of,  396 
lymphatics  of,  32 
nerves  of,  33 
palpation  of,  401 
by  sounds,  401 
prolapse  of,  586 
diagnosis,  587 
etiology,  586 
internal,  587 
operation  for,  588 
symptoms,  587 
treatment,  588 
stricture  of,  661 

treatment,  664 
tamponing  of,  in  hemorrhoids,  583 
temperature  in,  438 
tuberculosis  of,  549 
veins  of,  32 
Red  blood  corpuscles  in  feces,  419 
Reflex  vomiting,  379 
Regulin  in  constipation,  470 
Regiu-gitation,  375,  376 

of  bile,   permanent,  examination  of 
fasting  stomach  in,  112 
Reichmann's    disease,    291.     See    also 
Castrosuccorrhea  ■ 
rod,  76 
Reichmann   and   Heryng's    gastrodia- 

phane,  83 
Remond  and  Matthieu's  estimation  of 

chyme,  iii 
Renal    calculi,    gastralgia   and,    differ- 
entiation, 368 
Rennet,  absent,  105 
deficient,  105 
normal,  105 
tests  for,  105 
zymogen,  105 
Rennin,  35 

Resorcin  and  fluorescein  as  medium  in 
gastrodiaphany,  85 
and  phthalic  anhydria  as  medium  in 
gastrodiaphany,  85 


Resorcin-sugar    test    for    free    hydro- 
chloric acid,  97 
Respiratory  organs  in  typhoid   fever, 

530 
Rest  cure  in  gastric  ulcer,  228 
of  intestines  in  disease,  442 
Rhabdonema  intestinale,  707 
Rheumatism,  gastralgia  and,  differen- 
tiation, 368 
Rhubarb  in  constipation,  470 
Ricin  test  for  pepsin,  104 
Riegel's  test  dinner,  90 

for  free  hydrochloric  acid,  107 
Ringing  sounds  of  stomach,  81 
Roberts'  sphincter  dilator,  584 
Rogers'  small  red  dots  in  amebic  dysen- 
tery, 505 
Rontgen    rays    for    detecting    foreign 
body  in  stomach,  87 
in  chronic  amebic  dysentery,  519 

intestinal  obstruction,  660 
in  diagnosis  of  gastric  cancer,  255 
in  examination  of  intestines,  405 
in  investigating   intestinal   move- 
ments, 406 
in  treatment  of  gastric  cancer,  265 
physiologic     investigations     with, 

406 
to  locate  colon,  405 
Rontgenography  of  stomach,  87 
Rose's  apparatus  for  inflating  bowel,  79 
belt,  171,  172 

in  atony  of  stomach,  305 
in  constipation,  469 
in  intestinal  diseases,  440 
carbonic  acid  gas  generator,  406,  407 
dry  carbonic  acid  gas  bath  in  mucous 

colic,  678 
strapping  method  to  support  viscera, 
170 
Rosenbach's  test  for  indicanuria,  446 
Rosenheim-Ewald      stomach      douche 

tube,  156 
Rosenthal -Leube  meat  solution,  136 

method  of  lavage,  150 
Rosewater's  adhesive  belt,  175 
Rotary  movements  of  intestines,  40 
Rotation  of  intestinal  irrigation,  434 
Round  duodenal  ulcer,  543 

worms,  696 
Rubber  rectal  bag,  Kemp's,  581 
Rubs,  170 


INDEX 


755 


Rumination,  375,  370 

Runeberg's  colon-tube  for  inflating  in- 
testines, 407 

Russell's  diet  treatment  of  gastroptosis, 
356 

Russell-Hiss  type  of  bacillus  dysen- 
teriae,  521 

Saccharin,  test  for,  106 
Saccharobutyric  putrefaction,  447 
combined  with  indolic  type,  447 
auto-intoxication  in,  447 
Sago  grains  in  chronic  enteritis,  489 

in  feces,  410 
Sahli's  desmoid  test  for  gastric  juice, 

108 
Saline  rectal  enema,  137 

solution,  injection  of,  into  intestines, 

429 
waters  in  chronic  gastritis,  199 
Saliva,  ferments  of,  34 
Salol  for  tapeworm,  691 

test  for  motor  power,  122 
Salt,  effect  of,  on  kidneys,  130 
Sand  in  feces,  416 
intestinal,  456 
false,  457 
Sanitation,  dysentery  and,  502 
Santonin  for  ascaris  lumbricoides,  699 
Sarcinse  in  gastric  contents,  117,  119 
Sarcoma  of  intestines,  570 

of  stomach,  275 
Schistosoma  Cattoi,  695 
haematobium,  693 
Japanicum,  695 
Schlesinger  and  Hoist's  test  for  blood 

in  gastric  contents,  114 
Schmidt's  treatment   of  gastric  ulcer, 

231 
Schmidt-Strasburger    diets    to    deter- 
mine intestinal  functions,  421 
fermentation  test  for  feces,  425 
Scirrhous  carcinoma  of  stomach,  242 
Sclerosis  of  stomach,  cancer  and,  differ- 
entiation, 255 
ventriculi,  191,  192,  204 
Scolecoiditis,   591.     See  also  Appendi- 
citis. 
Scotch  douche,  170 

Scratch   method   of   auscultatory   per- 
cussion of  stomach,  76 
of  percussion,  52,  54 


Seasoning  of  foods,  peristalsis  and,  443 

Seat-worm,     699.     See     also     Oxyuris 
vermicular  is. 

Secretin,  37 

Secretory    function    of    stomach,    ex- 
amination, 90 
neuroses  of  intestines,  671 
of  stomach,  380 

Semina  cucurbitse  for  tapeworm,  691 

Senator's   treatment   of  gastric  ulcer, 
231 

Sensory  neuroses  of  intestines,  669 
of  stomach,  360,  364 

Septicemia,   posttyphoid,   534 

Serous  coat  of  large  intestine,  33 
of  small  intestine,  25 
of  stomach,  19 

Serumtherapy  in  bacillary  dysentery, 

527 
in  typhoid  fever,  538 
Shiga  serum  in  dysentery,  527 

type  of  bacillus  dysenteriae,  521 
Siever    and    Ewald's    test    for    motor 

power,  122 
Sigmoid,  double-current  needle  douche 
for,  439 
flexure,  31 

diver ticiila  and,  627 
palpation  of,  398 
volvulus,  639 
speculum,  Kelly's,  397 
Sigmoiditis,  620.     See  Diverticulitis. 
Sigmoidoscope,  398,  399 
Sigmoidoscopy,  396 
Silk  elastic  belt,  179 
Silver    nitrate    treatment    of    chronic 

gastric  erosions,  238 
Simple  percussion,  52 
Sims'  rectal  speculum,  397 
Single-tube  irrigation  of  intestines,  430 
Sitophobia,  364 
Siturgy,  363 

Sizzling  sounds  of  stomach,  82 
Skatol  in  feces,  tests  for,  426 
Skin  burns,  intestinal  ulcers  from,  546 
symptoms,  551 
treatment,  553 
diseases,  stomach  functions  in,  391 
eruptions,  auto-intoxication  in,  391 
vSmall  calorie,  1 24 

intestine,     22.     See     also     Intestine, 
small. 


756 


INDEX 


Smoking  in  chronic  gastritis,  199 
Soda  bicarbonate  and  tartaric  acid  to 
determine  position  of  stomach,  79 
in  hyperchlorhydria,  289,  290 
Sodium  iodid  in  gastric  cancer,  266 
Soft  rectal  bougie,  401 
Solitary  follicles  of  small  intestine,  27 
Solms-Jacoby  test  for  pepsin,  104 
Sounds,  esophageal,  use  of,  46,  47 

for  palpating  rectum,  401 
Soups  and  mushes  with  milk  diet,  133 
chemic  composition  of,  132 
meat,  pastry,  and  butter  with  milk 
diet,  134 
Sour  milks  in  typhoid  fever,  537 
Spallanzani  and  Edinger's  test  of  un- 

aspirated  gastric  contents,  108 
Sparing  stomach,  feeding  and,  136 
Spasm  of  cardia,  373 
diagnosis,  374 
etiology,  373 
prognosis,  374 
symptoms,  373 
treatment,  374 
of  pylorus,  372 
of  sphincter  ani,  461 
treatment,  472 
of  stomach,   365.     See  also  Gastral- 
gia. 
Spastic  constipation,  460 

treatment,  469 
Specula,  rectal,  396-399 
Sphincter  ani,  internal,  32 
spasm  of,  461 
treatment,  472 
dilatation  of,  for  hemorrhoids,  5S4 
paralysis  of,  668 
Spider   gall-bladder   adhesions,    gastric 

ulcer  and,  differentiation,  223 
Spilling,  51 
liver,  58 
spleen,  62 
Spinal  disease,  gastralgia  from,  366 
Splanchnoptosis,    341.     See   also   Gas- 

troptosis. 
Splashing  sounds  in  intestinal  diseases, 
400 
of  intestines,  differentiation   from 

stomach  splash,  81 
of  stomach,  80 

and  intestines,  differentiation,  81 
conclusions  regarding,  89 


Spleen,  anatomic  relations  of,  61 
dulness  of,  63 
floating,  64 
in  typhoid  fever,  530 
in  uncinarial  dermatitis,  705 
inspection  of,  62 
palpation  of,  62 
percussion  of,  63 
physical  examination  of,  62 
spUling,  62 
topography  of,  61 
Splenic  flexure  of  transverse  colon,  31 
Sponging  in  typhoid  fever,  537 
Spool    worm,    697.     See    also    Ascaris 

lumbricoides. 
Sporozoa,  681 
Spray,  gastric,  158.     See  also  Stomach 

spray. 
Staining  bacteria  in  feces,  425 
Stamper  method   of  localizing  gastric 

ulcer,  223 
Starch  digestion,  examination  of,  105 
intermediary  stages,  106 
Lugol's  solution  for   determining, 

106 
tests  for,  106 
granules  in  gastric  contents,  118 
in  feces,  410 

examination  for,  412 
Starvation  treatment  in  gastric  ulcer, 

228 
Static  electricity,  164 
Steam  coil,  continuous,  169 
Steapsin,  37 

test  for,  113 
Steatorrhea,  414 

pancreatic  disease  and,  414 
Steele's  diet  to  test  intestinal  functions, 

422 
Stenosis,    diverticular,     carcinomatous 
stenosis  and,  differentiation,  631 
of  cardia  in  cancer,  treatment,  275 
of    intestines,     657.     See     also    In- 
testines, obstruction  of. 
of  liver,  syphilitic,  gastric  cancer  and, 

differentiation,  256 
of  pylorus,  diet  in,  1 38 

gastralgia  and,  differentiation,  367 
laparotomy  in,  262 
syphilitic,  393 
of     stomach,     gastric     cancer     and, 
differentiation,  259 


IXDEX 


757 


Stenosis  with  obstruction  in  diverticu- 
litis, 630 
Stenotic  dilatation  of  stomach,  71 
Stercoral  diarrhea,  474,  476 
Stomach,    abscess    of,    1S8.     See    also 

Gastritis,  plilegmo/ious. 
adenocarcinoma  of,  242 
anatomy  of,  17,  18,  71 
antiperistaltic  restlessness  of,  371 
areolar  coat  of,  19 
arteries  of,  2 1 
atony  of,  303,  372.     See  also  Atony 

of  stomach. 
atrophy  of,    203.     See  also   Achylia 

gastrica. 
blood-vessels  of,  19,  20 
bucket,  E  inborn' s,  109 
cancer  of,   240.     See  also  Cancer  of 

stomach. 
capacity  of,  19,  320 
carcinoma  of,  240.     See  also  Cancer 

of  stomach. 
cardiac  glands  of,  20 

orifice  of,  17 
catarrh  of,    180.     See  also  Gastritis. 
chyme  within,  determination,  1 1 1 
coats  of,  1 9 

contents,   91.      See  also  Gastric  con- 
tents. 
cul-de-sac  of,  greater,  17 
curvatures  of,  18 
deglutition  sounds  in,  81 
digestion  in,  35 
dilatation  of,   306.     See  also  Ectasy 

of  stomach. 
dimensions  of,  19 
diseases,  71 

diet  in,  138 

electricity  in,  161.     See  also  Elec- 
tricity in  stomach  diseases. 

functional,  279 

high-frequency  current  in,  164 

static  electricity  in,  164 

Tiirck's  gyromele  in,  164 
dislocation  of,  341 
douche,  155 

alternate  hot  and  cold,  157 

bulb-compression  method,  157 

double-current,  156 

Einhorn's  instrument  for,  156 

Gross'  double-current,  156 

in  atony,  158,  333 


Stomach  douche,  medication  by,  156 

technic,  156,  157 

temperature  of  fluid,  1 58 

time  for,  156 

Y-method,  157 
dripping  sounds  of,  81 
ectasy  of,   306.     See  also  Ectasy  of 

stomach. 
electrodes,  161-163 
epithelioma  of,  242 
erosions  of,  236.     See  also  Erosions 

of  stomach. 
esophageal  orifice  of,  1 7 
faradism  to,  163,  164 
fasting,  bile  in,  113 

contents  of,  112 

duodenal  juice  in,  113 

intestinal  juice  in,  113 

pancreatic  juice  in,  113 
fermentation  in,  gas,  no 
fibroma  of,  275 
fore-,  340 
foreign  bodies  in,  277 

Rontgen  rays  for,  87 
form  of  anomalies  in,  340 
functional  diseases  of,  279 
functions  of,   absorptive  determina- 
tion, 121 

examination  of,  90 

in  acne  rosacea,  391 
simplex,  391 

in  acute  febrile  diseases,  387 

in  anemia,  389 

in  aneurj-sm,  390 

in  arteriosclerosis,  391 

in  arthritis  deformans,  391 

in  chlorosis,  389 

in  chronic  febrile  diseases,  38S 

in  digestion,  34 

in  diseases  of  other  organs,  387 

in  eczema,  391 

in  erythema,  391 

in  febrile  diseases,  387,  38S 

in  gout,  391 

in  heart  lesions,  389 

in  influenza,  391 

in  kidney  diseases,  390 

in  liver  diseases,  390 

in  malaria,  391 

in  nephritis,  390 

in  pemphigus  of  mouth,  392 

in  phthisis,  388 


758 


INDEX 


Stomach,  functions  of,  in  pneumonia, 

387 

in  psoriasis,  391 

in  pulmonary  tuberculosis,  388 

in  skin  diseases,  391 

in  typhoid  fever,  387 

in  urticaria,  391 

motor,  122 

disturbances  of,  303 

diet  in,  139 
in  hyperchlorliydria,  283 
quantity  of  ingesta  and,  95 
test  breakfast  for,  122 

meal  for,  122 
tests  for,  122 
fundus  of,  1 7 

glands  of,  20 
galvanism  to,  163,  164 
gas  fermentation  in,  1 10 
glands  of,  20 
greater  curvature  of,  18 
gurgling  sounds  of,  81 
Head's  zones  for,  612 
hemorrhage  of,  211 
hour-glass,  340 
hyperesthesia  of,  364 
hypermotility  of,  369 
in  appendicitis,  602 
in  uncinarial  dermatitis,  705 
inflammation   of,    suppurative,    188. 

See  also  Gastritis,  phlegmonous. 
inflation  of,  conclusions  regarding,  89 

with  air,  78 

with  carbonic  acid  gas,  77 

with  water,  78 
inspection  of,  72 

conclusions  regarding,  88 
irrigation  of,  140.     See  also  Lavage. 
lavage  of,   140.     See  also  Lavage. 
lesser  curvature  of,  18 
lipoma  of,  275 
local  treatment  of,  140 
lower  border  of,  locating,  326,  327 
lymphatics  of,  21,  262 
massage  of,  165.     See  also  Massage. 
mechanical  support  of,  170 

indications,  170 
medullary  carcinoma  of,  242 
motor  function  of,  35 

disturbances  of,  303 

neuroses  of,  369 
mucous  coat  of,  20 


Stomach,  mucous  glands  of,  20 
muscular  coat  of,  19 
myoma  of,  275 
nerves  of,  22 

nervous  affections  of,  359 
neuralgia  of,  365.     See  also  Gastral- 

gia. 
neuroses   of,  chronic    gastritis    and, 
differentiation,  195 

motor,  369 

secretory,  380 

sensory,  360,  364 
palpation  of,  73 

conclusions  regarding,  88 
percussion  of,  74 

auscultatory,  74 
scratch  method,  76 

conclusions  regarding,  88 
perforation  into,   in  colonic  cancer, 

564 
peristalsis  of,  72 
peristaltic  unrest  of,  72,  370 
peritoneal  coat  of,  19 
physical  examination  of,  71 

preparation  of  patient,  72 
polypoid  excrescences  of,  275 
position  of ,  1 7,  7 1 

anomalies  in,  340 

determining,  77-80 

Dehio's  method,  78,  79 
powder-blower,  159 

Einhorn's,  159,  160 

indications,  161 
prolapse  of.     See  Gastroptosis. 
pyloric  glands  of,  20 
radium  photographs  of,  88 
ringing  sounds  of,  81 
Rontgenography  for,  87 
Rose's  strapping  method  to  support, 

170-175 
sarcoma  of,  275 

sclerosis  of,  cancer  and,  differentia- 
tion, 255 
secretion  of,  disturbances  of  diet  in, 

139 
secretory   function   of,   examination, 
90 

neuroses  of,  380 
sensations  within,  363 
sensory  neuroses  of,  360,  364 
serous  coat  of,  19 
sizzling  sounds  of,  82 


INDEX 


759 


Stomach,    spasm    of,    365.       See    also 

Gasiralgia. 
splashing  sounds  of,  So 

conclusions  regarding,  89 
differentiation     from    intestinal 
splash,  Si 
spray,  158 

Einhorn's  tube  for,  158 

in  atonic  ectasy,  333 

in       gastrosuccorrhea       continua 
chronica,  301 

indications  for,  159 

technic,  159 
stenosis  of,  gastric  cancer  and,  differ- 
entiation, 259 
strapping  to  support,  1 70 
stricture  of,  diet  in,  138 
structure  of,  19 
submucous  coat  of,  19,  20 
succussion  sounds  of,  81 
supermotility  of,  369 
syphilis  of,  392 
tapotement  of,  165 
tongue  as  mirror  of,  45 
transillumination   of,    83.     See   also 

Gastrodiapiiany. 
Traube's  space  of,  19 
tumors  of,  240,  275 

apparent,  277 

cancer  and,  differentiation,  255 

determination  of,  76 

syphilitic,  393 
ulcer    of,    212.     See    also    Ulcer    of 

stomach. 
unrest  of,  peristaltic,  370 
veins  of,  2 1 
vertical,  349,  350 
volume  of,  18 

weak,  predisposition  to,  180 
Stomach-tube,  cyanosis  during  passing 

of,  144 
for  douche,  1 56 

for  examination  of  esophagus,  250 
for  lavage,  cleansing,  142 

double-current,  153 

Knapp's  director  as  aid  in  passing, 
152,  153 

one-piece,  141 

passing  of,  143 
selection  of,  141 

size  of,  142 

slipping  of,  into  stomach,  141 


Stomach-tube  for  lavage,   testing   of, 
141 
two-piece,  141 
occlusion  of,  during  lavage,  146 
passage  of,  47 
removal  of,  145,  146 
Stomach-whistle,  Kemp's,  79 

to  determine  position  of  stomach,  79 
Stools.     See  Feces. 
Storm's  abdominal  support,  179 
Strangulation  by  adhesions,  636,  637 
by  bands,  636,  637 
by  hernia,  internal,  636,  638 
by  Meckel's  diverticulum,  637 
course,  652 
diagnosis,  635 
herniaform,  internal,  636,  638 

mechanism,  639 
through  apertures,  637 
slits,  637 
Strapping,   adhesive,  in  intestinal  dis- 
eases, 440 
to  support  viscera,  170 
with  narrow  strips,  175 
Strasburger's  fermentation  tube,  426 
Strasburger-Schmidt  diets  to  test   in- 
testinal functions,  421 
fermentation  test  for  feces,  425 
Strauss  funnel  method  for  lactic  acid, 

lOI 

mixing  funnel,  10 1 

Stricture  of  colon,  inflation  with  water 
in,  408 
of  esophagus,  47 

in  cancer  of  cardia,  250 
of  rectum,  661 

treatment,  664 
of  stomach,  diet  in,  138 

Strongyloides  intestinalis,  707 

Strongylus  duodenalis,   701.     See  also 
Uncinariasis. 

Strophulus     infantum,     auto-intoxica- 
tion in,  391 

Subacidity,  diet  in,  139 

Subjective  Head  zones,  612 

Sublimate  test  for  bile-pigment  in  feces, 

425 
Submucous  coat  of  large  intestine,  33 

of  small  intestine,  25 

of  stomach,  19,  20 
Subphrenic  abscess,  termination,  220 
Succinic  acid,  Knapp's  test  for,  121 


760 


INDEX 


Succus  entericus,  38 

gastricus,  35 
Succussion  in  intestinal  diseases,  400 

sounds  of  stomach,  81 
Sugar,  chemic  composition  of,  132 

in  feces,  412 

tests  for,  106 
Sugar-bouillon  tubes,  425 
Summer,  food  in,  130 
Superacidity,    279.     See    also    Hyper- 

chlorhydria. 
Superficial  ulceration  of  stomach,  235 
Superior  mesenteric   artery,   occlusion 

of,  555 
Supermotility  of  stomach,  369 
Suprapapillary    cancer    of    duodenum, 

565 
Suprarenal    extract    in    treatment    of 

gastric  erosions,  239 
Syncope,  auto-intoxication  in,  323 
of  intestines,  551 
symptoms,  551 
treatment,  553 
of  stomach,  392 

cancer  and,  differentiation,  255 
Syphilitic  cirrhosis  of  stomach,  393 
gastric  ulcer,  393 
pyloric  stenosis,  393 
tumor  of  stomach,  393 
Syrup  of  figs  in  constipation,  470 

Tabes,  gastralgia  from,  366 
Tachycardia,  auto-intoxication  in,  312 

with  acute  ectasy  of  stomach,   311, 
312 
Taenia  cucumerina,  690 

elliptica,  690 

flavopunctata,  690 

lata,  689 

Madagascariensis,  689 

mediocanellata,  688 

nana,  689 

saginata,  688 

solium,  686 
Tamarinds  in  constipation,  470 
Tapeworms,  685 

armed,  686 

beef,  688 

description,  686 

pig  head,  689 

pork,  686 

treatment,  690 


Tapeworms,  unarmed,  688 
Tapotement  of  stomach,  165 
Tapping  of  stomach  in  massage,  165 
Tartaric  acid  and  soda  bicarbonate  to 

determine  position  of  stomach,  79 
Tea,  136 

in  test  meal,  91 
Teeth,  care  of,  136 
Telling's  classification  of  diverticulitis, 

630 
Temperature,    high,     auto-intoxication 

in,  323 
Tenesmus   in   amebic   dysentery,    512, 

514 
carbonic  acid  gas  for,  519 
in    bacillary    dysentery,    treatment, 

525 
in  hemorrhoids,  577 
Test  breakfast.  Boas',  90 

Ewald  and  Boas',  90 

for  motor  power,  122 

in  gastric  cancer,  252 
diet,  Schmidt-Strasburger,  421 

Steele's,  422 

to  determine  intestinal  functions, 
421 
dinner,  Riegel's,  90 
meal,  90 

Boas',  90 

for  motor  power,  122 

Ewald' s,  90 

Ewald  and  Boas',  90 

for  motor  power,  122 

Germain  See's,  90 

Kemp's,  91 

motor  power,  122 

Klemperer's,  90 

Leube's,  for  motor  power,  122 

oil,  to  secure  trypsin,  420 

Riegel's,  90 

special,  91 

tea  in,  91 
Tetany,  acute  ectasy  of  stomach  in,  311 
gastric,     auto-intoxication    in,     311, 

336,  337 
gastrosuccorrhea    continua   chronica 

and,  differentiation,  299 
in  atonic  ectasy  of  stomach,  331 

treatment,  335 
in  ectasy  of  stomach,  336 

Chvostek's  symptom,  337 
diagnosis,  337 


INDEX 


761 


Tetany   in   ectasy  of    stomach,   Erb's 
sign  in,  337 
etiology,  336 
frequency,  338 
Hoffmann's  sign  in,  337 
pathology,  336 
prognosis,  338 
symptoms,  337 
treatment,  338 
Trousseau's  symptom,  337 
in  gastric  cancer,  249 
in  stenotic  ectasy  of  stomach,  treat- 
ment, 336 
Thiosinamin  in  gastric  cancer,  267 
Thirst  in  gastric  ulcer,  treatment,  225 
in  gastrosuccorrhea  continua  period- 
ica, treatment,  295 
Thread  impregnation  test  for  localiz- 
ing gastric  ulcer,  223 
test  of  gastric  contents,  Dunham's, 
109 
Thread-worm,   699.     See  also  Oxyuris 

vermicularis . 
Thrombosis  in  gastric  cancer,  249 
of  inferior  mesenteric  artery,  557 
of  mesenteric  arteries,  554 
clinical  symptoms,  556 
diagnosis,  557 
etiology,  555 
prognosis,  557 
treatment,  558 
veins,  554,  557 
etiology,  555 
treatment,  558 
of  portal  vein,  555,  557 
superior  mesenteric  artery,  555 
Thrombotic  intestinal  ulcers,  547 
symptoms,  551 
treatment,  553 
Thymol  in  ascaris  lumbricoides,  699 

in  uncinarial  dermatitis,  706 
Thynms  in  treatment  of  gastric  cancer, 

273 
Tissue  shreds  in  feces  in  intestinal  ul- 
cers, 553 
Tongue  as  mirror  of  stomach  condition, 

45 
inspection  of,  45 
Tonsils,  inspection  of,  46 
Topfer's  method  for  total  acidity,  99 
quantitative    test    for    free    hydro- 
chloric acid,  97,  98,  99 


Topfer's  test  for  acid  salts,  99,  100 

for    combined    hydrochloric    acid, 

99 
Tormina  intestinorum,  666.     See  also 
Peristaltic  unrest. 
ventriculi  nervosa,  370 
Total  acidity,  Topfer's  method  for,  99 
Toxic  gastritis,  185.     See  also  Go5/nVij, 
toxic. 
ulcers  of  intestines,  550 
Transillumination  in  gastric  cancer,  248 
of  intestines,  404 

of  stomach,  83.       See  also  Gasirodi' 
apliany. 
Transverse  colon,  31 
palpation  of,  398 
position  of,  19 
Traube's  space,  19 
Trousseau's  symptom  of  gastric  tetany, 

337 
Trematodes,  692 
blood,  693 
liver,  692 
Tremoliere's  solution  in  gastric  cancer, 
274 
in  hemorrhage   of  amebic  dysen- 
tery, 519,  520 
Trichina  spiralis,  709 
in  muscle,  708 
intestinal,  709 
Trichiniasis,  709 
Trichocephalus  dispar,  708 
Trichomonas  hominis '  in    gastric    con- 
tents, 117 
intestinalis,  682 
Tropaolin-00  test  for  free  hydrochloric 

acid,  106 
True  diverticula,  623,  624 
Trypsin,  37 
in  feces,  415 

oil  test  meal  to  secure,  420 
test  for,  1 13,  420 

treatment  of  gastric  cancer,  253,  268, 
269 
of  intestinal  cancer,  570 
T-tube  lavage,  150 
Tubercle  bacilli  in  feces,  in   intestinal 

tuberculosis,  553 
Tuberculosis,  ileocecal,  Head's  zone  in, 

615 
of  colon,  549 
of  ileum,  549 


762 


INDEX 


Tuberculosis  of  intestines,  548,  549 

symptoms,  551 

treatment,  553 

tubercle  bacilli  in  feces  in,  553 
of  jejunum,  549 
of  rectum,  549 
pulmonary,    stomach    functions    in, 

388 
Tumefaction  in  appendicitis,  603 
Tumor  fragments  in  feces,  419 
of  liver,  percussion  of,  60 
of  pancreas,  61 
of  stomach,  240,  275 

apparent,  277 

determination  of,  76 

gastric  cancer  and,  differentiation, 

255 
syphilitic,  393 
particles  in  gastric  contents,  119 
phantom,  55 
Tiirck's  double-current  needle  douche 
for  sigmoid,  439 
gyromele,  164 
nebulizer,  439,  440 
Turpentine  for  tapeworm,  691 
Tuttle's   pneumatic  proctoscope,    397, 

399 
Tympanites,  451 
etiology,  451 
hystericus,  451 

in  acute  intestinal  obstruction,  647 
in  appendicitis,  treatment,  616,  617, 

618 
in  chronic  intestinal  obstruction,  660 
in  typhoid  fever,  312,  532,  533 

treatment,  538 
in  volvulus,  640 
nervous,  451 
prognosis,  452 
symptoms,  452 
treatment,  452 
Typhlitis,  591 

Typhoid  bacillus,  528.     See  also  Bacil- 
lus typhosus. 
fever,  528 

acute  ectasy  of  stomach  in,  312 

age  and,  528 

bacilluria  in,  533 
treatment,  541 

bacillus  typhosus  as  cause,  528 

baths  in,  537 

bladder  in,  530 


Typhoid  fever,  blood  in,  533 
bone-marrow  in,  530 
bones  in,  533 
bowels  in,  537 
Brand  treatment,  537 
chronic  distribution,  535 
circulatory  organs  in,  531 
colitis  in,  treatment,  541 
constipation  in,  539 
convalescence,  541 
diagnosis,  534 
diarrhea  in,  539 
diazo-reaction  in,  533 
diet  in,  535 

digestive  functions,  535 
dilatation  of  intestine  in,  postural 
treatment,  539 
of  stomach   in,   postural   treat- 
ment, 539 
distribution,  chronic,  535 
Ehrlich's  diazo-reaction  in,  533 
etiology,  528 
gall-bladder  in,  530 
gelatin  in,  536 
healing  of  intestines  in,  530 
heart  stimulants  in,  540 
hemorrhage  in,  death  from,  530 

treatment,  539 
history,  528 
hyperplasia  in,  529 
immunity  from,  528 
intestines  in,  529 
kidneys  in,  530 
leukopenia  in,  533 
liver  in,  530,  533 
medication  in,  537 

mesenteric  glands  in,  530 

milk  in,  537 

morbid  anatomy,  529 

Nauheim  baths  in,  537 

necrosis  in,  530 

nervous  system  in,  531 
treatment,  541 

neuritis  in,  533 

onset,  532 

osseous  system  in,  533 

perforation  in,  530,  533,  540 

peritonitis  in,  540 

Peyer's  patches  in,  529     . 

prevalence,  528 

prognosis,  534 

prophylaxis,  534 


INDEX 


763 


Typhoid  fever,  pulse  in,  532 
pyemia  after,  534 
rectal  irrigations  in,  536,  537 
renal   insuflficiency   in,    treatment, 

541 
respiratory  organs  in,  530 
season  and,  528 
septicemia  after,  534 
serumtherapy  in,  538 
sex  and,  528 

sleeplessness  in,  treatment,  541 
sour  milks  in,  537 
spleen  in,  530 
sponging  in,  537 
stomach  functions  in,  387 
symptoms,  531 
temperature  in,  531 
treatment,  535 
tympanites  in,  312,  532,  533 

treatment,  538 
ulceration  in,  530 
voluntary  muscles  in,  531 
Widal's  reaction  in,  534 
Typholumbricosis,  698 

UFFELMann's  test  for  lactic  acid,  100 

modified,  10 1 
Ulcer,    duodenal,    gastric    ulcer    and, 
differentiation,  223 
perforating,  543 
round,  543 
simple,  543 
age  and,  543 
clinical  aspects,  544 
complications,  544 
course,  545 
diagnosis,  545 
etiology,  543 
gastric  analysis  in,  545 

ulcer  and,  differentiation,  223, 

545 

hemorrhage  in,  545 

pathology,  543 

prognosis,  546 

sex  and,  543 

site  of,  543 

surgical  treatment,  546 

symptoms,  544,  551 

treatment,  546,  553 

vomitus  in,  545 
of  colon,  549,  550 
of  intestines,  543 


Ulcer  of  intestines,  amyloid,  547 

symptoms,  551 

treatment,  553 
blood  in  feces  in,  552 
cancerous,  551 

symptoms,  551 

treatment,  553 
catarrhal,  550 
decubital,  550 

symptoms,  551 

treatment,  553 
diarrhea  in,  552 
diet  in,  554 
embolic,  547 

symptoms,  551 

treatment,  553 
feces  in,  552 
fever  in,  553 
follicular,  550 
from  cutaneous  burns,  546 
symptoms,  551 
treatment,  553 
girdle,  549 
gonorrheal,  551 

symptoms,  551 

treatment,  553 
hemorrhage  in,  552 
in  acute  infectious  diseases,  550 
in  chronic  enteritis,  489 
in  constitutional  diseases,  550 
symptoms,  551 
treatment,  553 
in  infectious  diseases,  symptoms, 

551 
treatment,  553 
mucus  in  feces  in,  553 
nutrition  in,  553 
pain  in,  553 
perforation  in,  553 
prognosis,  553 
pus  in  feces  in,  552 
stercoral,  550 

S5anptoms,  551 

treatment,  553 
symptoms,  551 
syphilitic,  551 

symptoms,  551 

treatment,  553 
thrombotic,  547 

symptoms,  551 

treatment,  553 
tissue  shreds  in  feces  in,  553 


764 


INDEX 


Ulcer  of  intestines,  toxic,  550 
symptoms,  551 
treatment,  553 

treatment,  553 

tubercular  bacilli  in  feces  in,  553 
primary,  548 
secondary,  549 
symptoms,  551 
treatment,  553 
of  stomach,  212 

achylia  gastrica  and,  214 

age  in  etiology,  213 

anemia  in  etiology,  2 1 3 
treatment,  230 

cancer  engrafted  on,  257 

chlorosis  in  etiology,  213 

cholelithiasis  and,   differentiation, 
221 

chronic  gastritis  and,   differentia- 
tion, 194 

cicatrization  in,  215 

cirrhosis  of  liver  and,   differentia- 
tion, 223 

collapse  in,  225 

complications,  218 

course,  223 

diagnosis,  220—223 
differential,  221,  222 

diet  in,  138,  226 

Dieulafoy's,  235 

duodenal    ulcer    and,    differentia- 
tion, 223,  545 

egg-albumen  diet  in,  229 

Einhorn's  treatment,  228 

etiology,  212 

experimental,  213 

extent  of,  215 

free  hydrochloric  acid  in,  227 

frequency,  212 

from  diphtheria  toxin,  213 

gastralgia  and,  differentiation,  367 

gastric  carcinoma  and,  differentia- 
tion, 221,  222,  259 
contents  in,  218 
crises  of  locomotor  ataxia  and, 

223 
stamper   method    of   localizing, 
223 

gastrosuccorrhea  continua  chron- 
ica and,  differentiation,  298 

gelatin  treatment,  231,  232 

geographic  distribution,  212 


Ulcer  of  stomach,  hematemesis  in,  217 

treatment,  224 
operative,  235 
hyperchlorhydria  and,  214,  218 

differentiation,  221,  285 
Kemp's  treatment,  231 
laparotomy  in,  235 
latent  cases,  216 
lavage  in,  234 
Lenhartz's  treatment,  228 
Leube-Ziemssen  rest  cure  in,  228 
location,  215,  223 
microscopic  appearance,  215 
milk  diet  in,  226 
morbid  anatomy,  214 
motor  function  in,  218 
nervous  dyspepsia  and,  differentia- 
tion, 383 

gastralgia    and,    differentiation, 
221,  222 
number,  215 

nutritive  enemata  in,  227,  228 
occupation  in  etiology,  2 1 3 
operative  treatment,  235 
pain  in,  217,  218 

treatment,  234 
perforation  in,  219 

treatment,  234,  235 
physical  signs,  219 

with  little  air  present,  220 
with  much  air  present,  220 
prognosis,  224 
progress,  215 

progressive  necrosis  in,  215 
rest  cure  in,  226,  228 
Schmidt's  treatment,  231 
Senator's  treatment,  231 
sex  in  etiology,  212 
simulating  hyperchlorhydria,    216 
spider  gall-bladder  adhesions  and, 

differentiation,  223 
starvation  treatment  in,  228 
stools  in,  218 
surgical  treatment,  235 
sjmiptoms,  216 
syphilitic,  393 
terminations,  220 
theories  of,  213 
thirst  in,  treatment,  225 
thread  impregnation  test  for  local- 
izing, 223 
traumatism  in  etiology,  213 


INDEX 


76: 


Ulcer  of  stomach,  treatment,  224 
general  principles,  226 
of  collapse,  225 
of  hemorrhage,  224 
of  pain  in,  234 
of  perforation,  234,  235 
of  thirst,  225 
of  vomiting,  234 
operative,  235 
tuberculous,  389 
typical  case,  216 
urine  in,  218 

vomiting  in,  treatment,  234 
Weinland's  theory,  213 
peptic,  212.     See  also  Ulcer  of  stom- 
ach. 
undermined,    in    amebic    dysentery, 
506 
Ulcus  duodeni  pepticum,  543.     See  also 
Ulcer,  duodenal,  simple. 
ventriculi,    212.     See   also    Ulcer   of 
stotnach. 
Umbilicus,  position  of,  47 
Unarmed  tapeworm,  688 
Uncinaria  Americana,  702,  703 
Uncinarial  dermatitis,  703 
anemia  in,  705 
blood  in,  705 
bone-marrow  in,  705 
diagnosis,  706 
hemolymph  glands  in,  705 
immunity,  704 
intestines  in,  705 
kidneys  in,  704 
liver  in,  704 
lungs  in,  704 
morbid  anatomy,  704 
prognosis,  706 
prophylaxis,  706 
spleen  in,  705 
stomach  in,  705 
symptoms,  704 
treatment,  706 
Uncinariasis,  701 
incidence,  701 
parasite  of,  702 
Ureter,  Head's  zone  for,  614 
Urine,    elimination    of    decomposition 

products  in,  39 
Urobilin  in  feces,  413 
Urticaria,  auto-intoxication  in,  391 
from  foods,  364 


Urticaria,  stomach  functions  in,  391 
Uterine  adnexa.  Head's  zone  for,  615 
Uterus,  Head's  zone  for,  615 

perforation    into,    in   rectal    cancer, 

564 
Uvula,  inspection  of,  46 

Vaccine,  cancer,  274 

Vacuum  bottle  for  proctoclysis,  437 

Vagina,     perforation    into,     in     rectal 

cancer,  564 
Vaginal  examination,  digital,  51 

in  appendicitis,  602 
Valvulse  conniventes  of  Kerkring,  25 
Van    Deen's    test    for    occult    blood, 

Weber's  modification,  115 
Vedee  vibrator,  165,  166 
Vegetable  and  animal  foods,  difference, 

127 
Vegetables,  chemic  composition  of,  131 
Veins,   mesenteric,    embolism   of,    554. 
See  also  Em,holism. 
thrombosis     of,      554.     See     also 
Thrombosis. 
of  cecum,  32 
of  colon,  32 
of  rectum,  32 
of  small  intestine,  24 
of  stomach,  21 
Venous  hemorrhoids,  575 
Ventriculi,  cirrhosis,  191,  192,  204 
phthisis,    191,    192,    203,    204.     See 

also  Achy  Ha  gastrica. 
sclerosis,  191,  192,  204 
Vermes,  685 
Vermiform    appendix.     See    Appendix 

vermiformis. 
Vertical  stomach,  349,  350 
Vertigo  in  constipation,  463 
Vibrators,  165,  166 
Vibratory  massage,  165 

in  atonic  ectasy  of  stomach,  333 
in  chronic  gastric  atony,  305 

gastritis,  197 
in  constipation,  467 
Vichy  water  in  hyi)erchl()rliydria,  289 
Villi  of  small  intestine,  26 
Viscera,  mechanical  support  of,  170 
Visceral  arteriosclerosis,  455 
Visceroptosis,   341.     See  also  Gastrop- 

tosis. 
Volatile  acids  in  gastric  contents,  102 


766 


INDEX 


Voluntary  muscles  in   typhoid  fever, 

531 
Volvulus,  639 

age  and,  640 

anatomy,  641 

course,  641,  652 

definition,  639 

differential  diagnosis,  650 

etiology,  640 

frequency,  640 

mechanics,  639 

of  sigmoid  flexure,  639 

of  small  intestine,  640 

pain  in,  640 

prognosis,  653 

sex  and,  640 

symptoms,  640 

treatment,  653 

tjmipanites  in,  640 

vomiting  in,  640 
Vomit,  bile  in,  112 

blood  in,  112 

examination  of,  1 1 1 

food  in.  III 

mucus  in,  112 

parasites  in,  112 
Vomiting,  cyclic,  in  children,  378 

in  acute  intestinal  obstruction,  647 

in  chronic  intestinal  obstruction,  659 
treatment,  664 

in  gastric  cancer,  246 
treatment,  274 
ulcer,  treatment,  234 

in  intussusception,  643,  644 

in  pertussis,  Kilmer's  belt  in,  I75-I79 

juvenile,  379 

nervous,  377 
idiopathic,  379 

of  blood,  211 


Vomiting,  periodic,  378 

reflex,  379 

significance  of,  1 1 1 ,  112 
Von  Leyden's  periodic  vomiting,  378 
Von   Noorden's   determination   of  hy- 
drochloric acid  deficit,  107 

diet  lists,  132,  133,  134 

AVar,  dysentery  in,  502 
Water  infiltration  method  for  hemor- 
rhoids, Gant's,  586 

inflation  of  colon  with,  408 
of  stomach  with,  78 
Weak  stomach,  predisposition  to,  180 
Weber's  modification   of   Van    Deen's 

test  for  occult  blood,  115 
Weinland's  theory  of  gastric  ulcer,  213 
Wet,  diarrhea  from,  475 
Whip-worm,  708 

Whitehead's     operation     for     hemor- 
rhoids, 586 
Widal's  reaction  in  typhoid  fever,  534 
Wines  as  food,  1 36 
Wolff's  artificial  Carlsbad  salts,  290 

formula  for  Carlsbad  salts,  199 
W^orms,  685 

fluke-,  692 

in  feces,  415 

round-,  696 

X-RAYS.     See  Rdntgen  rays. 

Yeast-cells  in  gastric  contents,  118, 

119 
Y-method  of  spraying  stomach,  157 
Y-tube  lavage,  150 

Ziemssen-Leube  rest  cure  in  gastric 
ulcer,  228 


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the  text,  and  has  added  many  new  illustrations,  greatly  enhancing  the  value  of 
the  work.  The  articles  on  Dislocations,  illustrated  in  that  practical  manner 
which  has  made  Dr.  Scudder' s  work  so  useful,  will  be  found  extremely  val- 
uable. 

Joseph  D.  Bryaoit,  M.D.,  Professor  of  the  Principles  and  Pi'actice  of  Surgery,  University 
and  Bellevue  Hospital  Medical  College. 

"As  a  practical  demonstration  of  the  topic  it  is  excellent,  and  as  an  example  of  bookmaking 
it  is  highly  commendable." 


Bickham's   Operative   Surgery 

A  Text=Book  of  Operative  Surgery.  By  Warren  Stone  Bickham, 
M.  D.,  Phar.  M.,  of  New  Orleans.  Octavo  of  1200  pages,  with  854 
original  illustrations.     Cloth,  $6.50  net;  Half  Morocco,  ^$8.00  net. 

THE    NEW    (3d)   EDITION 

This  absolutely  new  work  completely  covers  the  surgical  anatomy  and  opera- 
tive technic  involved  in  the  operations  of  general  surgery.  The  practicability  of 
the  work  is  particularly  emphasized  in  the  854  magnificent  illustrations  which  form 
a  useful  and  striking  feature. 

Boston  Medical  and  Sur^^ical  Journal 

"The  book  is  a  valuable  contribution  to  the  literature  of  operative  surgery.  It  represents 
a  vast  amount  of  careful  work  and  technical  knowledge  on  the  part  of  the  author.  For  the  sur- 
geon in  active  practice  or  the  instructor  of  surgery,  it  is  an  unusually  good  review  of  the  subject." 


SAUNDERS'  BOOKS  ON 


Bier's 
Hyperemic  Treatment 

By  WILLY  MEYER,  M.  D.,  and  Prof.  V.  SCHMIEDEN 


Bier's  Hyperemic  Treatment  in  Surgery,  Medicine,  and  the  Special- 
ties :  A  Manual  of  its  Practical  Application.  By  Willy  Meyer,  M.  D., 
Professor  of  Surgery  at  the  New  York  Post-Graduate  Medical  School 
and  Hospital ;  and  Prof.  Dr.  Victor  Schmieden,  Assistant  to  Prof. 
Bier,  University  of  Berlin,  Germany.  Octavo  of  280  pages,  with 
original  illustrations.     Cloth,  ;^3.oo  net 

RECENTLY   ISSUED— NEW   (2d)    EDITION— FOR  THE   PRACTITIONER 

For  the  practitioner  this  work  has  a  particular  value,  because  it  gives  special 
attention  to  the  hyperemic  treatment  of  those  conditions  with  which  he  comes  in 
daily  contact.  Yet  the  needs  of  the  surgeon  and  the  specialist  have  not,  by  any 
means,  been  neglected.  The  work  is  not  a  translation,  but  an  entirely  original 
book,  by  Dr.  Willy  Meyer,  who  has  practised  the  treatment  for  the  past  fifteen 
years,  and  Prof.  Schmieden,  Professor  Bier's  assistant  at  Berlin  University.  In 
the  first  part  the  three  methods  of  inducing  hyperemia  are  described;  in  the  second, 
are  taken  up  the  details  of  apphcation. 

New  York  State  Journal  of   Medicine 

"  We  commend  this  work  to  all  those  who  are  interested  in  the  treatment  of  infections, 
either  acute  or  chronic,  for  it  is  the  only  authoritative  treatise  we  have  in  the  English  language." 


Campbell's  Surg^ical  Anatomy 

A  Text=Book  of  Surgical  Anatomy.  By  William  Francis  Camp- 
bell, M.  D.,  Professor  of  Anatomy,  Long  Island  College  Hospital. 
Octavo  of  675  pages,  with  319  original  illustrations.  Cloth,  ;^5.0o  net; 
Half  Morocco,  $6.50  net. 

WITH     319     PRACTICAL     ILLUSTRATIONS 

The  first  aim  in  the  preparation  of  this  original  work  was  to  emphasize  the 
practical.  It  is  in  the  fullest  sense  an  applied  anatomy — an  anatomy  that  will  be 
of  inestimable  value  to  the  surgeon  because  only  those  facts  are  discussed  and 
only  those  structures  and  regions  emphasized  that  have  a  peculiar  interest  to  him. 
Dr.  Campbell  has  treated  his  subject  in  a  very  systematic  way.  The  magnificent 
original  illustrations  will  be  found  extremely  practical. 

Boston  Medical  and  Surgical  Journal 

"  The  author  has  an  excellent  command  of  his  subject,  and  treats  it  with  the  freedom  and 
the  conviction  of  the  experienced  anatomist.     He  is  also  an  admirable  clinician." 


SURGER  V  AND  ANA  TOM\ 


Schultze  and  Stewart's 
Topog(raphic  Anatomy 

Atlas  and  Text=Book  of  Topographic  and  Applied  Anatomy.     By 

Prof.  Dr.  O.  Schultze,  of  Wurzburg.  Edited,  with  additions,  by 
George  D.  Stewart,  M.D.,  Professor  of  Anatomy  and  Clinical  Sur- 
gery, University  and  Bellevue  Hospital  Medical  College,  N.  Y.  Large 
quarto  of  189  pages,  with  25  colored  figures  on  22  colored  lithographic 
plates,  and  89  text-cuts,  60  in  colors.     Cloth,  ^5.50  net. 

WITH    BEAUTIFUL    COLORED    PLATES 

It  was  Professor  Schultze' s  special  aim,  in  preparing  this  work,  to  produce  a 
Text-Book  and  Atlas,  not  for  the  anatomist  alone,  but  more  particularly  for  the 
general  practitioner.  The  value  of  the  knowledge  of  topographic  anatomy  in  bed- 
side diagnosis  is  emphasized  throughout  the  book.  The  many  colored  lithographic 
plates  are  exceptionally  excellent. 

Arthur  Dean  Bevan.  M.  D.,  Professor  of  Stirgery  in  Rush  Medical  College,  Chicago. 

"  I  regard  Schultze  and  Stewart's  Topographic  and  Applied  Anatomy  as  a  very  admirable 
work,  for  students  especially,  and  I  find  the  plates  and  the  text  excellent." 

Sobotta  and  McMurrich*s 
Human  Anatomy 

Atlas  and  Text-Book  of  Human  Anatomy.  In  Three  Volumes.  By 
J.  Sobotta,  M.D.,  of  Wurzburg.  Edited,  with  additions,  by  J.  Playfair 
McMurrich,  a.  M.,  Ph.  D.,  Professor  of  Anatomy,  University  of 
Toronto,  Canada.  Three  large  quartos,  each  containing  about  250 
pages  of  text  and  over  300  illustrations,  mostly  in  colors.  Per  volume : 
Cloth,  ^6.00  net ;  Half  Morocco,  ^7.50  net. 

VOLUME    III    NOW    READY— COMPLETING    THE     WORK 

The  oreat  advantage  of  this  over  other  similar  works  lies  in  the  large  number 
of  mao-nificent  lithographic  plates  which  it  contains,  without  question  the  best  that 
have  ever  been  produced  in  this  field.     They  are  accurate  and  beautiful  reproduc- 
tions of  the  various  anatomic  parts  represented. 
Edweo'd  Martin,  M.D.,  Professor  of  Clinical  Surger/,  University  of  Pennsylvania. 

"This  is  a  piece  of  bookmaking  which  is  truly  admirable,  with  plates  and  text  so  well 
chosen  and  so  clear  that  the  work  is  most  useful  to  the  practising  surgeon." 


lo  SAUNDERS'   BOOKS  ON 


Eisendrath's 
Surgical  Diag'nosis 

A  Text=Book  of  Surgical  Diagnosis.  By  Daniel  N.  Eisendrath, 
M.D.,  Professor  of  Surgery  in  the  College  of  Physicians  and  Surgeons, 
Chicago.  Octavo  of  885  pages,  with  574  entirely  new  and  original 
text-illustrations  and  some  colored  plates.  Cloth,  $6.50  net;  Half 
Morocco,  38.00  net. 

JUST   ISSUED— THE    NEW    (2d)    EDITION 

Of  first  importance  in  exerj  surgical  condition  is  a  correct  diagnosis,  for  upon 
this  depends  the  treatment  to  be  pursued  ;  and  the  two — diagnosis  and  treatment — 
constitute  the  most  practical  part  of  practical  surger}-.  Dr.  Eisendrath  takes  up 
each  disease  and  injury  amenable  to  surgical  treatment,  and  sets  forth  the  means 
of  correct  diagnosis  in  a  systematic  and  comprehensive  way.  Definite  directions 
as  to  methods  of  examination  are  presented  clearly  and  concisely,  providing  for 
all  contingencies  that  might  arise  in  any  given  case.  Each  illustration  indi- 
cates precisely  how  to  diagnose  the  condition  considered. 

Surgery,  Gynecology,  and  Obstetrics 

"The  book  is  one  which  is  well  adapted  to  the  ttses  of  the  practising  surgeon  who  desires 
intormation  concisel)'  and  accurately  given.  .  .  .  Nothing  of  diagnostic  importance  is  omitted, 
yet  the  author  does  not  run  into  endless  detail." 


E^isendrath's  Clinical  Anatomy 

A  Text=Book  of  Clinical  Anatomy.  By  Daniel  N.  Eisendrath, 
A.B.,  M.D.,  Professor  of  Surgery  in  the  College  of  Physicians  and 
Surgeons,  Chicago.  Octavo  of  535  pages,  illustrated.  Cloth,  ^5.00 
net;  Half  Morocco,  ;$6.50  net. 

THE   NEW   (2d)   EDITION 

This  new  anatomv  discusses  the  subject  from  the  clinical  standpoint.  A  por- 
tion of  each  chapter  'is  devoted  to  the  examination  of  the  living  through  palpation 
and  marking  of  surface  outlines  of  landmarks,  vessels,  nerves,  thoracic  and 
abdominal  viscera.  The  illustrations  are  from  new  and  original  drawings  and 
photographs.     This  edition  has  been  carefully  revised. 

Medical  Record,  New  York 

"  \  special  recommendation  for  the  figures  is  that  they  are  mostly  original  and  were 
made  for  the  purpose  in  view.  The  sections  of  joints  and  trunks  are  those  of  formalmized 
cadavers  and  are  unimpeachable  in  accuracy." 


SURGERY  AND  ANATOMY  ii 

Moynihan*s 
Abdominal  Operations 


Abdominal  Operations.  By  B.  G.  A.  Moynihan,  M.  S.  (Lond.), 
F.R.C.S.,  Senior  Assistant  Surgeon,  Leeds  General  Infirmary,  England. 
Octavo,  beautifully  illustrated.    Cloth,  ^7.00  net ;  Half  Morocco,  ^8.50  net. 

THE    NEW    (2d)    EDITION 
TWO    LARGE    EDITIONS    IN    ONE    YEAR 

It  has  been  said  of  Mr.  Moynihan  that  in  describing  details  of  operations  he 
is  at  his  best.  The  appearance  of  this,  his  latest  work,  therefore,  will  be  widely 
welcomed  by  the  medical  profession,  giving,  as  it  does,  in  most  clear  and  exact 
language,  not  only  the  actual  modus  operatidt  of  the  various  abdominal  operations, 
but  also  the  preliminary  technic  of  preparation  and  sterilization.  Complications 
and  sequela;  and  after-treatment  are  presented  in  the  same  clear,  clean-cut  manner 
as  the  operations  themselves.  The  beautiful  illustrations  have  been  especially  drawn. 

Edward  Martin,  M.  D. 

Professor  of  Clinical  Su7'gery,  University  of  Pennsylvania 

"  It  is  a  wonderfully  good  book.  He  has  achieved  complete  success  in  illustrating,  both 
by  words  and  pictures,  the  best  technic  of  the  abdominal  operations  now  commonly  performed." 


Moynihan  on  Gall-stones 


Qall=stones  and  Tlieir  Surgical  Treatment.  By  B.  G.  A.  Moyni- 
han, M.S.  (Lond.),  F.R.C.S.,  Senior  Assistant  Surgeon,  Leeds  General 
Infirmary,  England.  Octavo  of  458  pages,  fully  illustrated.  Cloth, 
$  5.00  net;  Half  Morocco,  $6.50  net. 

THE    NEW   (2d)    EDITION 

Mr.  Moynihan,  in  revising  his  book,  has  made  many  additions  to  the  text,  so 
as  to  include  the  most  recent  advances.  Especial  attention  has  been  given  to  a 
detailed  description  of  the  early  symptoms  in  cholelithiasis,  enabling  a  diagnosis 
to  be  made  in  the  stage  in  which  surgical  treatment  can  be  most  safely  adopted. 
Every  phrase  of  gall-stone  disease  is  dealt  with,  and  is  illustrated  by  a  large 
number  of  clinical  records.  The  account  of  the  operative  treatment  of  all  the 
forms  and  complications  of  gall-stone  disease  is  full  and  accurate.  A  number  of 
the  illustrations  are  in  color. 

Britiah  Medical  JoumzJ 

"  He  expresses  his  views  with  admirable  clearness,  and  he  supports  them  by  a  large  num- 
ber of  clinical  examples,  which  will  be  much  prized  by  those  who  know  the  difficult  problems 
and  tasks  which  gall-stone  surgery  not  infrequently  presents." 


12  SAUNDERS'  BOOKS  ON 


Gould's  Operations  on  the 
Intestines  and  Stomach 

The  Technic  of  Operations  upon  the  Intestines  and  Stomach.     By 

Alfred  H.  Gould,  M.  D.,  of  Boston.     Large  octavo,  with  190  original 
illustrations,  some  in  colors.     Cloth,  $5.00  net ;  Half  Morocco,  |6.5Ciiet. 

WITH    190    ORIGINAL    ILLUSTRATIONS 

Dr.  Gould' s  new  work  is  the  result  of  exhaustive  experimentation,  the  technic 
of  the  operations  described  being  simpHfied  as  far  as  possible  by  experiments  on 
animals,  thus  leading  to  the  development  of  many  new  features.  The  text  is  pur- 
posely concise,  the  technic  being  presented  very  clearly  by  the  numerous  practical 
illustrations,  all  made  from  actual  operations  done  either  upon  the  animal  or  the 
human  being.  As  the  success  of  gastro-intestinal  surgery  depends  upon  an  accur- 
ate knowledge  of  the  elementary  steps,  a  thorough  account  of  repair  is  included. 

New  York  State  Journal  of  Medicine 

"  The  illustrations  are  so  good  that  one  scarcely  needs  the  text  to  elucidate  the  steps  of 
the  operations  described.     The  work  represents  the  best  surgical  knowledge  and  skill." 


DaCosta*s  Modern  Surgery 

Modern  Surgery — General  and  Operative.  By  John  Chalmers 
DaCosta,  M.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery  in  the 
Jefferson  Medical  College,  Philadelphia.  Octavo  of  1283  pages,  with 
872  illustrations.     Cloth,  ^5.50  net;  Half  Morocco,  $7.00  net. 

THE     NEW    (5th)    EDITION 

For  this  new  fifth  edition  the  work  has  been  entirely  rewritten  and  reset.  One 
hundred  and  fifty  new  illustrations  have  been  added  ;  and  the  work  has  been  en- 
larged by  the  addition  of  two  hundred  pages.  To  keep  the  book  of  a  size  to  handle 
conveniently,  a  thinner  but  high-grade  paper  has  been  used.  DaCosta's  Surgery 
in  this  edition  will  more  than  maintain  the  reputation  already  won. 

Boston  Medical  and  Surgical  Journal 

"  We  commend  the  book,  as  we  have  previously  commended  it,  to  surgeons  and  to  students 
as  the  most  satisfactory  one-volume  contemporaneous  treastise  on  surgery  published  in  this 
country." 


SURGER  Y  AND  ANA  TOMY  ^  3 


Preiswerk   and  Warren's   Dentistry 

Atlas  and  Epitome  of  Dentistry.  By  Pkof.  G.  Preiswerk,  of  Basil.  Ed- 
ited, with  additions,  by  George  W.  Warren, D.D.S.,  Professor  of  Operative 
Dentistry,  Pennsylvania  College  of  Dental  Surgery,  Philadelphia.  With  44 
lithographic  plates,  152  text-cuts,  and  343  pages  of  text.  Cloth,  #3.50  net 
hi  Saunders   Atlas  Series. 

"  Nowhere  in  dental  literature  have  we  ever  seen  illustrations  which  can  begin  to  compare 
with  the  exquisite  colored  plates  produced  in  this  volume." — Dental  Review. 

Griffith's  Hand-Book  of  Surgery 

A  Manual  of  Surgery.  By  Frederic  R.  Griffith,  M.  D.,  Surgeon  to  the 
Bellevue  Dispensary,  New  York  City.  i2mo  of  579  pages,  with  417  illus- 
trations. Flexible  leather,  $2.00  net. 

"  Well  adapted  to  the  needs  of  the  student  and  to  the  busy  practitioner  for  a  hasty  review  of  important 
points  in  surgery." — American  Medicine. 

Keen's  Addresses  and  Other  Papers 

Addresses  and  Other  Papers.  Delivered  by  William  W.  Keen,  M.  D., 
LL.D.,  F.  R.  C.  S.  (Hon.),  Professor  of  the  Principles  of  Surgery  and  of  Clin- 
ical Surgery,  Jefferson  Medical  College,  Philadelphia.  Octavo  volume  of 
441  pages,  illustrated.  Cloth,  ,$3.75  net. 

Keen  on  the  Surgery  of  TypKoid 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.     By  Wm.  W. 

Keen.  M.D.,  LL.D.,  F.R.C.S.  (Hon.),  Professor  of  the  Principles  of  Surgery 
and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia,  etc. 
Octavo  volume  of  386  pages,  illustrated.  Cloth,  $3.00  net. 

"  Every  surgical  incident  which  can  occur  during  or  after  typhoid  fever  is  amply  discussed  and  fully 
illustrated   by  cases.     .     .     .     The  book   will   be    useful  both   to  the   surgeon  and    physician." — 'J he 

Practitioner,  London. 

Lewis'  Anatomy  and  Physiology  for  Nurses 

Just  Ready— New  (2d)  Edition 
Anatomy  and  Physiology  for  Nurses.  By  LeRoy  Lewis,  M.  D.,  Surgeon 
to  and  Lecturer  on  Anatomy  and  Physiology  for  Nurses  at  the  Lewis  Hospital, 
Lay  City,  Michigan.     i2mo,  375  pages,  with  150  illustrations.    Cloth,  ;>  1.75  net. 

A  demand  for  such  a  work  as  this,  treating  the  subjects  from  the  nitrse's  point  of  view,  has 
long  existed.     Dr.  Lewis  has  based  the  plan  and  scope  of  this  work  on  tlie  methods  em- 
ployed by  him  in  teaching  these  branches,  making  the  te.xt  unusually  simple  and  clear. 
"  It  Is  not  in  any  sense  rudimentary,  but  comprehensive  in  its  treatment  of  the  subjects  in  hand." — 
Nurses  Journal  of  the  Pacific  Coast. 

McClellan*s  Art  Anatomy 

Anatomy  in  Its  Relation  to  Art.  By  George  McClellan,  M.  D.,  Professor 
of  Anatomy,  Pennsylvania  Academy  of  the  Fine  Arts.  Quarto  volume,  9  by 
12^  inches,  with  338  original  drawings  and  photographs,  and  260  pages  of 
text.      Dark  blue  vellum,  #10.00  net  ;  Half  Russia,  $12.50  net. 


14  SAUNDERS'   BOOKS   ON 

Haynes*  Anatomy 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.D.,  Professor  of  Prac- 
tical Anatomy,  Cornell  University  Medical  College.  Octavo,  680  pages, 
with  42  diagrams  and  134  full-page  half-tones.  Cloth,  I2.50  net. 

American  Pocket  Dictionary  ""ISS^eSh 

The  American  Pocket  Medical  Dictionary.     Edited  by  W.  A.  Newman 

Borland,  A.M.,M.D.,  Assistant  Obstetrician,  Hospital  of  the  University  of 
Pennsylvania,  etc.  598  pages.  Full  leather,  limp,  with  gold  edges,  $1.00 
net;  with  patent  thumb  index,  I1.25  net. 

Grant  on  Face,  Mouth,  and  Jaws 

A  Text=Book  of  the  Surgical  Principles  and  Surgical  Diseases  of  the 
Face,  Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace  Grant, 
A.M.,  M.D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  Hospital  College 
of  Medicine.     Octavo  of  231  pages,  with  68  illustrations.       Cloth,  I2.50  net. 

Fowler's    Surgery  in  Two  Volumes 

A  Treatise  on  Surgery.  By  George  R.  Fowler,  M.  D.,  Emeritus  Pro- 
fessor of  Surgery,  New  York  Polyclinic.  Two  imperial  octavos  of  725  pages 
each,  with  888  original  text-illustrations  and  4  colored  plates.  Per  set : 
Cloth,  ^15.00  net ;  Half  Morocco,  $18.00  net. 

International  Text- Book  of  Surgery  second  Edition 

The  International  Text=Book  of  Surgery.  In  two  volumes.  By  Ameri- 
can and  British  authors.  Edited  by  J.  Collins  Warren,  M.  D.,  LL.  D., 
F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical  School ;  and  A. 
Pearce  Gould,  M.  S.,  F.  R.  C.  S.,  of  London,  England.  Vol.  I.  :  General 
and  Operative  Surgery.  Royal  octavo,  975  pages,  461  illustrations,  9  full- 
page  colored  plates.  Vol.  II.  :  Special  or  Regional  Surgery.  Royal  octavo, 
1 122  pages,  499  illustrations,  and  8  full-page  colored  plates.  Per  volume  : 
Cloth,  $5.00  net  ;   Half  Morocco,  $6. 50  net. 

American  Text-Book  of  Surgery  Fourth  Edition 

American  Text=Book  of  Surgery.  Edited  by  W.  W.  Keen,  M.  D., 
LL.  D.,  Hon.  F.  R.  C.  S.,  Eng.  and  Edin.,  and  J.  William  White, 
M.  D.,  Ph.  D.  Octavo,  1363  pages,  551  text-cuts  and  39  colored  and 
half-tone  plates.     Cloth,  1^7.00  net  ;   Half  Morocco,  ^8.50  net. 

Robson  and  Cammidge  on  the  Pancreas 

The  Pancreas :  Its  Surgery  and  Pathology.  By  A.  W.  Mayo  Robson, 
F.  R.  C.  S.,  of  London,  England  ;  and  P.  J.  Cammidge,  F.  R.  C.  S.,  of 
London,  England.  Octavo  of  546  pages,  illustrated.  Cloth,  $5.00  net ; 
Half  Morocco,  $6.50  net. 


SURGERY  AND   ANA  TO  Ml.  15 

American  Illustrated  Dictionary  The  New  (si^fE^'duion 

The  American  Illustrated  Medical  Dictionary.  With  tables 
of  Arteries,  Muscles,  Nerves,  Veins,  etc.  ;  of  Bacilli,  Bacteria,  etc. ; 
Eponymic  Tables  of  Diseases,  Operations,  Stains,  Tests,  etc.  By  W.  A. 
Newman  Borland,  M.D.  Large  octavo,  876  pages.  Flexible  leather, 
^4.50    net;  with  thumb  index,  ^5.00  net. 

Howard  A.  Kelly,  M.D.,  Prof cssor  of  Gynecology ,  Johns  Hopkins  University,  Baltimore. 

"Dr.  Borland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  con- 
venient size.     No  errors  have  been  found  in  my  use  of  it." 

Golebiewski  and  Bailey's  Accident  Diseases 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.      By  Dr. 

Ed.  Golebiewski,  of  Berlin.  Edited,  with  additions,  by  Pearce  Bailey, 
M.D.  Consulting  Neurologist  to  St.  Luke's  Hospital,  New  York  City. 
With  71  colored  figures  on  40  plates,  143  text-cuts,  and  549  pages  of 
text.  Cloth,  ^4.00  net.     In  Saunders'  Hand-Atlas  Series. 

Helferich  and  Bloodgood  on  Fractures 

Atlas  and  Epitome  of  Traumatic   Fractures  and  Dislocations 

By  Prof.  Dr.  H.  Helferich,  of  Greifswald,  Prussia.  Edited,  with  ad- 
ditions, by  Joseph  C.  Bloodgood,  M.  D.,  Associate  in  Surgery,  Johns 
Hopkins  University,  Baltimore.  216  colored  figures  on  64  lithographic 
plates,  190  text-cuts,  and  353pages  of  text.  Cloth,  $3.00  net.  In  Saun- 
ders' Atlas  Series. 

Sultan  and  Coley  on  Abdominal  Hernias 

Atlas  and  Epitome  of  Abdominal  Hernias.  By  Pr.  Dr.  G.  Sul- 
tan, of  Gottingen.  Edited,  with  additions,  by  Wm.  B.  Coley,  M.  D., 
Clinical  Lecturer  and  Instructor  in  Surgery,  Columbia  University,  New 
York.  119  illustrations,  36  in  colors,  and  277  pages  of  text.  Cloth, 
^3.00  net.     In  Saunders'  Hand-Atlas  Series. 

Warren's  Surgical  Pathology  ISn 

Surgical  Pathology  and  Therapeutics.  By  J.  Collins  Warren, 
M.D.,  LL.D.,  F.R.C.S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical 
School.  Octavo,  873  pages;  136  illustrations,  33  in  colors.  Cloth, 
^5.00  net;  Half  Morocco,  I6.50  net. 

Zuckerkandl  and  DaCosta*s  Surgery  Ed^^^ 

Atlas  and  Epitome  of  Operative  Surgery.  By  Dr.  O.  Zucker- 
KANDL,  of  Vienna.  Edited,  with  additions,  by  J.  Chalmers  DaCosta, 
M.  D.,  Professor  of  Surgery  and  Clinical  Surgery,  Jefferson  Medical  Col- 
lege, Phila.  40  colored  plates,  278  text-cuts,  and  410  pages  of  text. 
Cloth,  ^3.50  net.     In  Saunders'  Atlas  Series. 


l6  SURGER  V  AND  ANA  TOMY 


Moore's  Orthopedic  Surgery 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.D.,  Professor 
of  Clinical  Surgery,  University  of  Minnesota,  College  of  Medicine  and  Surgery. 
Octavo  of  356  pages,  handsomely  illustrated.  Cloth,  $2.50  net. 

"Ju^  '^  j°'^  '^  eminently  practical.  It  is  a  sate  guide  in  the  understanding  and  treatment  ot 
orthopedic  cases.    Should  be  owned  by  every  surgec-a  and  practitioner."— ^«>za/j  o/^M^^^yy. 

Fowler's  Operating  Room  New  (2d)  Edition 

The  Operating  Room  and  the  Patient.      By  Russell  S.  Fowler,  M.  D., 

Surgeon   to   the   German    Hospital,    Brooklyn,    New  York.      Octavo  of  284 

pages,  illustrated.  Cloth,  $2.00  net. 

Dr.  Fowler  has  written  his  book  for  surgeons,  nurses  assisting  at  an  operation,  internes, 
and  all  others  whose  duties  bring  them  into  the  operating  room.  It  contains  explicit 
directions  for  the  preparation  of  material,  instruments  needed,  position  of  patient,  etc., 
all  beautifully  illustrated. 

Nancrede's  Principles  of  Surgery      New  (2d)  Edition 

Lectures  on  the  Principles  of  Surgery.  By  Chas.  B.  Nancrede,  M.D., 
LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  University  of  Michigan, 
Ann  Arbor.     Octavo,  407  pages,  illustrated.  Cloth,  $2. 50  net. 

"  We  can  strongly  recommend  this  book  to  all  students  and  those  who  would  see  something 
of  the  scientific  foundation  upon  which  the  art  of  surgery  is  huWV— Quarterly  Medical  Journal, 
Sheffield,  England. 

Nancrede's  Essentials  of  Anatomy,    seventh  Edition 

Essentials  of  Anatomy,  including  the  Anatomy  of  the  Viscera.  By  Chas. 
B.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  University 
of  Michigan,  Ann  Arbor.  Crown  octavo,  388  pages  ;  180  cuts.  With  an 
Appendix  containing  over  60  illustrations  of  the  osteology  of  the  body.  Based 
on  G7-ay  s  Anatomy.         Cloth,  $1.00  net.     ht  Saunders   Question  Comp ends. 

"  The  questions  have  been  wisely  selected,  and  the  answers  accurately  and  concisely  given." — 

University  Medical  Magazine. 

Martin's  Essentials  of   Surgery.     ^^^Xvifed"""" 

Essentials  of  Surgery.  Containing  also  Venereal  Diseases,  Surgical  Land- 
marks, Minor  and  Operative  Surgery,  and  a  complete  description,  with  illus- 
trations, of  the  Handkerchief  and  Roller  Bandages.  By  Edward  Martin, 
A.M.,  M.D.,  Professor  of  Chnical  Surgery,  University  of  Pennsylvania,  etc. 
Cro^vn  octavo,  338  pages,  illustrated.  With  an  Appendix  on  Antiseptic  Sur- 
gery, etc.  Cloth,  $1.00  net.      In  Saunders'  Questmt  Compends. 

'■  Written  to  assist  the  student,  it  will  be  of  undoubted  value  to  the  practitioner,  containing  as  it 
does  the  essence  of  surgical  work." — Boston  Medical  and  Surgical  Journal. 

Martin's   Essentials  of  Minor  Surgery,  Band« 
aging,    and   Venereal    Diseases.       ^^^'"Edit'kjn^*^^** 

Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal  Diseases.    By 

Edward  Martin,  A.M.,  M.D.,  Professor  of  Clinical  Surgery,  University  of 

Pennsylvania,  etc.   Crown  octavo,  166  pages,  with  78  illustrations. 

Cloth,  ^i.oo  net.     In  Saunders''   Question  Competids. 

"The  best  condensation  of  the  subjects  of  which  it  treats  yet  placed  before  the  profession."— 
The  Medical  News,  Philadelphia. 


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